Incident Management Policy and Procedure 652.0 KB - Oxleas NHS ...

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- individual factors;- task factors;- communication factors;- team and social factors;- education and training factors;- equipment and resources factors;- working conditions and environmental factors;- organisation and strategic factors.Recommend solutionsRetrospective Barrier Analysis is the recommended tool to assess the effectiveness of exitingbarriers/controls and to develop additional and/or alternative solutions.A barrier is a defence or control measure to prevent harm to vulnerable or valuable objects (people,buildings, organisational reputation and the wider community). There are four main barriers inhealthcare: physical barriers, natural barriers, human action barriers and administrative barriers. Thefact that an incident has taken place means that one or more of the barriers have not been in place orhave failed. The analysis offers a structured way to visualise the events related to systems failure andcan be used to solve problems or evaluate existing barriers.This stage is designed to identify:• which barriers should have been in place to prevent the incident;• why the barriers failed; how they could be strengthened to prevent future failure;• which other barriers could be used to prevent the incident happening again.In recommending solutions care should be taken to base recommendations on root causes.Write the ReportThe RCA concludes with an investigation report. This needs to be written as soon as possible and in away that is accessible and understandable to all readers.The report should:• be simple and easy to read;• have an executive summary, index and contents page and clear headings;• include the title of the document and state whether it is a draft or the final version;• include the version date, reference initials, document name, computer file path and pagenumber in the footer;• disclose clinical information for which consent has been obtained, or if patientconfidentiality has been breached, this is balanced against public interest as confirmed bylegal advice;• include the evidence of the methodology used for investigation, for example RCA (includetimelines/cause and effect charts, brainstorming/brain writing, nominal group technique,use of a contributory factor framework and fishbone diagrams, five whys and barrieranalysis);• identify root causes and recommendations;20
• ensure that conclusions are evidenced and reasoned, and that recommendations canrealistically be implemented;• include a description of how patients/victims and families have been engaged in theprocess;• include a description of the support provided to patients/victims/families and staff followingthe incident.For further information on the RCA process, tools and templates please refer to the guidance on theNPSA website: www.npsa.nhs.uk4 SUPPORT FOR VICTIMS, PERPETRATORS, FAMILIES, CARERS AND STAFFThe NPSA has issued guidance to the NHS – Being open – communicating patient safety incidentswith patients and their carers. Although this guidance is primarily aimed at communication withpatients (and their families or carers) who have been harmed as a result of an error in their healthcare,the principles of honesty and openness also apply when planning discussions with victims,perpetrators, families and carers.The basic principles underlying this communication are the:• principle of acknowledgement;• principle of truthfulness, timeliness and clarity of communication;• principle of apology.When an incident leading to serious harm or death occurs, the needs of those affected are of primaryconcern to the trust, and those undertaking any investigation. Any contact should be undertaken in arespectful, dignified and compassionate manner, and in a spirit of openness. The service director willtake the lead, and agree with the family who the main family contact will be.Victims and families want to know:• What happened?• Why it happened?• How it happened?• What can be done to stop it from happening again to anyone else?The victim and family should be offered a meeting. The meeting should not take place at the site of theincident and staff involved in the incident should not be required to attend. The meeting should explainwhat support processes have been put in place and how they can be accessed.If victims and their families do not wish to participate in a meeting with the trust then informationshould be put in writing. If contact is initially rejected further attempts should be made to establishcontact and share information. If contact continues to be rejected in the case of homicide, the SHAshould be asked to take over responsibility for victim and family liaison.21
Page 2 and 3: VERSION CONTROLDocument LocationOxl
Page 4 and 5: PART AINTRODUCTION1.1 Oxleas NHS Fo
Page 6 and 7: to the Senior Officer within HR who
Page 8 and 9: Head of Safeguarding Children and L
Page 10 and 11: 2 REPORTING AND IMMEDIATE ACTION2.1
Page 12 and 13: Immediate Within 24 Hours Within 3
Page 14 and 15: HOMICIDEHomicideNHSLondongrade 2Imm
Page 16 and 17: 2.3 Reporting to external agenciesC
Page 18 and 19: 3 INITIAL SERVICE MANAGEMENT REVIEW
Page 22 and 23: 4.1 InformationVictims, families an
Page 24 and 25: Directorate investigations reports
Page 26 and 27: Type of incident Level 1NegligibleA
Page 28 and 29: Type of incident Level 1NegligibleL
Page 31 and 32: Appendix IIIIncident report form to
Page 33 and 34: Guidance notes for completing adver
Page 35 and 36: SERIOUS INCIDENTAppendix VPRIVATE A
Page 37 and 38: Date of discharge from most recent
Page 39 and 40: • Ensure that TOR’s and timesca
Page 41 and 42: Where the LSCB TOR includes service
Page 43 and 44: Appendix VIIIOXLEAS NHS FOUNDATION
Page 45 and 46: 5. CONTENT OF THE INVESTIGATION5.1
Page 47 and 48: Guidelines on writing witness state
Page 49 and 50: The following ‘‘do’s’’ an
Page 51 and 52: System owners may also be requested
Page 53 and 54: Strictly ConfidentialGreenwich Crit
Page 55 and 56: Strictly ConfidentialBexley Critica
Page 57 and 58: Strictly ConfidentialBromley Critic

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