Incident Management Policy Including Serious Incidents Requiring ...

Contents1 Introduction ........................................................................................................ 42 Definitions .......................................................................................................... 43 Duties................................................................................................................. 53.1 Individual Roles............................................................................................ 53.2 Committee Roles ......................................................................................... 84 Reporting an Incident ......................................................................................... 94.1 Violations ..................................................................................................... 94.2 Reporting Incidents Anonymouysly.............................................................. 95 Incident Investigation ......................................................................................... 95.1 Levels of Investigation ................................................................................. 95.2 Records ..................................................................................................... 105.3 Timescales................................................................................................. 105.4 Simple investigations ................................................................................. 106 Root Cause Analysis........................................................................................ 117 External Stakeholder Notification ..................................................................... 128 Reporting to External Agencies........................................................................ 128.1 National Patient Safety Agency (NPSA) .................................................... 128.2 Reporting of Injuries, Diseases and Dangerous Occurrences (RIDDOR) . 128.2.1 To Report a RIDDOR Incident:.......................................................................128.3 NHS Litigation Authority............................................................................. 148.4 Medical Devices Agency............................................................................ 148.5 Serious Hazards of Transfusion (SHOT) reporting. ................................... 148.6 Ionising Radiation (Medical Exposure) Regulations (IRMER) 2000. .......... 148.7 Information Commissioner ......................................................................... 148.8 NHS Counter Fraud & Security Management Service ............................... 149 Incident Grading And Subsequent Actions....................................................... 159.1 Adding risks highlighted by an incident investigation to the Risk Register. 1510 Public Communications.................................................................................... 1511 Recommendations and Action Planning .......................................................... 1612 Support for Patients, Carers, Relatives and others .......................................... 1612.1 Timing................................................................................................. 1612.2 Statements.......................................................................................... 1612.3 Staff support ....................................................................................... 1612.4 Whistleblowing.................................................................................... 1713 Link with Incident Management and Complaints Management ........................ 1714 What to Report as a Serious Incident Requiring Investigation (SUI) ................ 17Major Incidents/Terrorism and Chemical, Biological, Radiological or Nuclear (CBRN)Incidents................................................................................................................... 17Medico-legal incidents/litigation................................................................................ 17Mortality/Morbidity/Care Incidents ............................................................................ 18Safety and Governance Incidents ............................................................................ 19Health Protection (Major Outbreaks/Serious Incidents of Communicable Disease). 20Media Issues. ........................................................................................................... 2114.1 How to Report a Serious Incident (SUI) – Who And How ................... 2114.1.1 Grading Incidents.............................................................................................2114.2 The investigation and final report........................................................ 2515 Never events .................................................................................................... 2516 Management of Serial Incidents....................................................................... 252 of 28