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

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PART AINTRODUCTION1.1 Oxleas NHS Foundation Trust is committed to providing the highest standard of care for peoplein mental health, learning disability needs and community settings. Patient Safety in the Trustis enhanced by the use of health care processes, activities and working practices that preventor reduce the risk of harm to patients, staff and visitors.The Trust is committed to identifying and learning from all patient safety incidents and otherreportable incidents, and in making improvements in practice based on local and nationalexperience and information derived from the analysis of incidents.This document describes incident management processes and procedures.National regulatory bodies and best practice guidance provide the Trust with a framework forthe reporting, management, investigation and learning from incidents.The key drivers are:• Equality and excellence – Liberating the NHS (DoH July 2010)• Serious Incident• National Health Service Litigation Authority risk management standards (April 2008)• National Patient Safety Agency Seven Steps to Patient Safety• Independent Investigations of Serious Patient Safety Incidents in Mental Health ServicesGood Practice Guidance(NPSA Feb 2008)• Healthcare Commission core standards• Health and Safety Executive (HSE)• Department of Health guidance ’An Organisation with Memory (2000), ‘Doing Less Harm’(2001), and ‘Building a Safer NHS for Patients (2001)• ‘Being Open’ (2006)• Strategic Health Authority (NHS London) Guidance• Learning from investigations (Healthcare Commission, 2008)• London Child Protection Procedures (London Safe-guarding Children Board, 2007)• Working together to safeguard children 2010• National Framework for reporting and learning from serious incidents requiringinvestigation 2010• Checklist for reporting, managing and investigating information governance seriousuntoward incidents. Doh Jan 2010POLICY STATEMENTThe Trust has a responsibility to provide safe and effective services and promotes a safety consciousculture. It encourages all staff to report any patient, staff or visitor safety incident in order that; safetyissues are identified, investigation procedures are initiated and that learning from experience can takeplace. The Trust accepts that human errors occur, and does not seek to place unfair blame onindividuals. The methodology for investigation adopted by the Trust focuses on improving systemsand processes to prevent human error.However, there may be circumstances when disciplinary action will be in accordance with the TrustDisciplinary Policy. Disciplinary proceedings might be considered appropriate where there aregrounds for believing an employee:• has acted criminally or maliciously• is responsible for professional malpractice4
• has acted with gross misconduct• has a record of significant repetition of mistakes• or has not reported errors or violationsRAISING A MATTER OF CONCERN (WHISTLE BLOWING) PROCEDUREThe Trust promotes a culture of openness and transparency whereby staff and other workers areencouraged to raise a concern in confidence. The procedure applies to all employees of the Trust andalso contractors providing services, agency workers, home workers, and trainees on vocational andwork experience schemes, bank staff and those who hold honorary contracts. The procedure isavailable on the trust intranet at http://www.oxleasintranet.nhs.uk/library/1359.pdfSCOPE OF THE POLICYThe following adverse events fall within the scope of this policy:Adverse Incident/accident – Any unplanned and uncontrolled event which led to or could have led toloss to patient, member of staff or member of the public.Serious Incidents for investigation – Something out of the ordinary or unexpected, with the potentialto cause harm and /or likely to attract public and media interest that occurs on NHS premises or in theprovision of an NHS or a commissioned service. Please see appendix 11 for the appropriate boroughtemplate for the process for critical incident/SUI notification.Near miss - any unintended or unexpected incident that was prevented by some form of interventionand so resulted in no harm but without the intervention may have resulted in harm to one or morepersonsSecurity incident - thefts, deliberate damage to property etc.Never Event - The NPSA definition of a ‘Never Event’ is: A serious, largely preventable patient safetyincident that should not occur if the available preventative measures have been implemented byhealthcare providers.Reportable injuries, Diseases or Dangerous Occurrences (RIDDOR) – these are defined inSchedules1, 2 and 3 of the RIDDOR (1995) and are detailed in the Appendix VIII e.g. fractures, acuteillness requiring medical treatment, loss of sight of an eye, act of violence against staff resulting inthem being off work for more than 3 days.It applies to all incidents occurring in the previous 6 months that;a) occur on Trust premises or,b) occur off Trust premises but involve persons employed by the Trust whilst on Trust business or,c) involve any patient receiving care from the Trust – including joint mental health services withlocal authorities or,d) are unexpected deaths, apparent suicides, and homicides by former patients within 6 monthsof discharge.Safeguarding ChildrenWhere there is harm or potential harm to a child or young person, the incident management policyguidelines must be considered together with Safeguarding Children Policy and procedures.In addition, if the incident raises a concern that a member of staff has behaved in a way that has, ormay, harm a child or which indicates that s/he is unsuitable to work with children, this must be reported5
Page 2 and 3: VERSION CONTROLDocument LocationOxl
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 20 and 21: - individual factors;- task factors
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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