Incident Management Policy Including Serious Incidents Requiring ...

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FINDINGS:Chronology of eventsChronology (timeline) of eventsDate & Time EventDetection of incidentAdd text hereNotable practiceAdd text hereCare and service delivery problemsAdd text hereContributory factorsAdd text hereRoot causesAdd text hereLessons learnedAdd text herePost‐investigation risk assessmentAPotential severity(1-5)BLikelihood of recurrenceat that severity (1-5)CRisk rating(C = A x B)incident management policy 2011 with SUI v3 FINAL 36/51
CONCLUSIONS:RecommendationsAdd text hereArrangements for Shared LearningAdd text hereDistribution ListAdd text hereAppendicesAdd text hereAction PlanSee also ‘Types of Preventative Actions Planned’‐ tool at www.npsa.nhs.uk/rcaAction 1 Action 2 Action 3Root CAUSEEFFECT on patientRecommendationAction to address rootcauseLevel for action(Org, direct, team)Implementation by:Target date forimplementationAdditional resourcesrequired (Time,money, other)Evidence of progress andcompletionMonitoring and evaluationArrangementsSign off - actioncompleted date:Sign off by:incident management policy 2011 with SUI v3 FINAL 37/51
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 14 and 15: 8.3 NHS Litigation AuthorityThe Nat
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 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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