Serious Untoward Incident Policy - Health Partnerships Learning ...

Appendix K: - Serious Untoward Incident Policy: Audit toolThis checklist summarises the requirements of the Serious Untoward Incident [SUI] Policy1. Is the procedure for SUI reporting explained to all new staff as part of their CorporateInduction?YES/NO2. Have all Nottinghamshire Community Health’s SUI’s been reported to an AssistantDirector within 4 hours of their occurrence?YES/NO3. Have patients and relatives where appropriate been informed of SUIs under ‘Being Open’procedures and in all cases before any information disclosed to the media? YES/NO4. Have all NCH SUIs been reported to the PCT within one week of their occurrence?YES/NO5. Have all SUIs been appropriately recorded onto the Incident Reporting Database Datixand signed off when completed?YES/NO6. Has a Risk Assessment [Consequence and likelihood] been undertaken regarding thespecific type of SUI that has been reviewed?YES/NO7. Have all SUIs been appropriately recorded onto STEIS/UNIFY and signed off whencompleted?YES/NO8. Have all SUIs had a formal report completed within 60 days of the index event?YES/NO9. Have all SUIs had an action plan developed, implemented and monitored? YES/NO10. Have lessons learned from SUIs been shared across NCH and with stakeholders?YES/NO11. Has a summary report regarding SUI’s been submitted to Governance Committee atleast quarterly?YES/NO12. Have SUIs been included as part of the Annual Risk Management Report? YES/NOWhere .NO’ is a response an action plan should be devised to implement improvements.33