Incident Management Policy Including Serious Incidents Requiring ...

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8.3 NHS Litigation AuthorityThe National Health Service Litigation Authority (NHSLA) requires notification of any staffincident that results in over 10 days sickness absence period, fatal injuries, amputation toany limb, head injury and likely HSE prosecution. Managers/Supervisors should informthe Head of Governance of any such incidents as the Head of Governance reports to theNHSLA on behalf of Peninsula Community Health.8.4 Medical Devices AgencyThe Medical Devices Agency (MDA) must be notified where medical equipment is involvedin an incident leading to, or potentially leading to:DeathLife threatening illness or injuryDeterioration in healthTemporary or permanent impairment of body function or damageThe necessity for surgical or medical intervention to prevent permanent damage tobody function or structure.Unreliable test results leading to inappropriate diagnosis or therapy.Notification should occur before any repairs/modifications are made to the medical device.Manufacturers should not be allowed to inspect such equipment until permission has beengranted by the MDA. Where circumstances allow, medical devices should be removedfrom the department. If equipment cannot be moved due to size, fixtures etc., it must beclearly labelled and staff notified of the problem.Responsibility for MDA reporting lies with the Manager/Supervisor, who should liaise withCHESS and inform the Head of Governance that this has been done.8.5 Serious Hazards of Transfusion (SHOT) reporting.SHOT is a confidential, voluntary reporting system for serious adverse events followingtransfusion of blood components, these include (and are not limited to) giving the wrongblood to the patient, Transfusion transmitted infections and acute or delayed haemolytictransfusion reaction including anaphylaxis. All transfusion related incidents and nearmisses should be reported following the Peninsula Community Health procedures and alsoreported to the Blood Laboratory of the acute Trust providing the service who will report thecase to SHOT as appropriate.8.6 Ionising Radiation (Medical Exposure) Regulations (IRMER) 2000.As part of the regulation process, hospitals and other users of medical radiation arerequired to notify the Healthcare Commission of incidents where patients are exposed tolevels of radiation “much greater than intended”. For more information on IRMERregulations visit www.cqc.org.uk8.7 Information CommissionerSerious breaches of data protection/information governance, as defined in Section 7.1.4should be reported to the Information Governance Lead (Head of Governance).8.8 NHS Counter Fraud & Security Management ServicePeninsula Community Health will report all instances of violence and aggression against it’sstaff by patients or members of the public to the NHS Counter Fraud & Security14 of 28
Management Service. This will take place through the Peninsula Community Health LocalSecurity Management Specialist.9 Incident Grading And Subsequent ActionsAll incidents are graded by the investigating officer/handler based on actual severity of impact andlikelihood of recurrence using the descriptions below (from PCH Guide to Risk Assessment).DATIX will provide the final risk grading.Appendix 2 gives PCH’ guidance on deciding the impact and likelihood scores and also showshow these scores provide an incident grade of green, yellow, amber or red.The following table indicates the levels of action required for the different grades of incident:No harm/minimal harmAny immediate actionsnecessary. Ensure DATIXincident report completed.Report to external agencies asrequired. Investigation at locallevel by immediatemanager/supervisor. Learningshared across organisation asappropriateModerate/severe harm:Any immediate actions necessary.Ensure DATIX incident reportcompleted.Report to external agencies asrequired. Investigation withindepartment by manager/ supervisor,possibly with input from localmanagers and/or ‘specialists’ fromother teams.Results reported to Directorresponsible for area and learningshared across organisation asappropriate.DeathAny immediate actions necessary.Report immediately, internally andto external agencies as required,including reporting as asignificant untoward incident(section 6) if appropriate.Investigation and root causeanalysis by Manager involvingspecialists as appropriate.Report outcomes to Directorresponsible for area and learningshared across organisation asappropriate.Following investigation, the grading of the incident should be re-visited and amended asappropriate to ensure an accurate representation of the situation.9.1 Adding risks highlighted by an incident investigation to the Risk Register.Incidents and their investigations can often highlight areas of concern which cannotimmediately be addressed. For example there may be a need for additional staffing or achange in a care pathway. While these actions are being considered, there is a risk asimilar incident could occur. This risk should be assessed using PCH Guide to RiskAssessment. The assessment should be shared with the relevant teams and managersand also sent to the Head of Governance.10 Public CommunicationsSometimes Peninsula Community Health may wish to seek the involvement of the media inincident management, for example where there may be a recall, or a public health concern.Peninsula Community Health may also wish to work closely with the media to ensure the incidentevents and PCH actions are accurately reflected.The Communications team in PCH will co-ordinate all media relations as necessary/ appropriate inline with PCH Communications Strategy and will maintain contemporaneous records of all contactand information shared with the media.15 of 28
Page 1 and 2: Peninsula Community HealthIncident
Page 3 and 4: 17 Performance Management and Data
Page 5 and 6: the case of those in receipt of men
Page 8 and 9: Director of Finance will Retain ove
Page 10 and 11: No harm/minimal harmAny immediate a
Page 12 and 13: 7 External Stakeholder Notification
Page 16 and 17: If a staff member is contacted by t
Page 18 and 19: impending court hearing or out of c
Page 20 and 21: Category 0 1 2 3 4 5Impact No signi
Page 22 and 23: Peninsula Community HealthSERIOUS I
Page 24 and 25: Action requiredMonitoring requiredE
Page 26 and 27: 17 Performance Management and Data
Page 28 and 29: 23 Referenceso Data Protection Act
Page 30 and 31: ContentsExecutive Summary 33MAIN RE
Page 32 and 33: MAIN REPORT:Incident description an
Page 34 and 35: FINDINGS:Chronology of eventsChrono
Page 36 and 37: Appendix B - Organisational Risk Ma
Page 38 and 39: Consequence score (severity levels)
Page 40 and 41: Grade 2 (requiring independent inve
Page 42 and 43: - immediate actions taken;- details
Page 44 and 45: will continue to monitor the action
Page 46 and 47: Where an incident meets the require
Page 48 and 49: Wrong routeadministration ofchemoth
Page 50 and 51: Initial Equality and Human Rights I
Page 52 and 53: 3. How does it impact on people’s

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