Incident Management Policy Including Serious Incidents Requiring ...

closure of the incident. Details of the key milestones and proposed procedures are includedbelow:9. In all cases incidents should be reported on the Strategic Executive InformationSystem (STEIS) within two working days of identification of the event.10. Guidance on the types of incidents that should be reported can be found in theNational Patient Safety Agency document ‘Information Resource to Support theReporting of Serious Incidents’ available from the National Patient Safety Agencywebsite. Please note this guidance is not exhaustive.11. Incidents should be graded as 0, 1 or 2 in accordance with grading definitions statedwithin the National Framework (Page17). Incident grades should be agreed with theCommissioning Primary Care Trust (PCT) for grade 1 incidents and theCommissioning Primary Care Trust and Strategic Health Authority (SHA) for grade 2incidents. The grading of the incident should be entered on the ‘furtherinformation’ section of STEIS;12. The ongoing monitoring of grade 1 incidents will be monitored by the commissioningPCT. Grade 2 incidents will be monitored by the Commissioning PCT in conjunctionwith the SHA.13. Timescales for investigation will be dependent on the grade of the serious incident.The following timescales will apply:Grade 0 Notification only (it is unclear if a serious incident has occurred). The providerorganisation must update the PCT/SHA with further information within three workingdays. If not a serious incident, it can be downgraded with agreement of PCT/SHA. Ifa serious incident it will be re graded accordinglyGrade 1 45 working days from the date the incident is notified.Grade2 (Those incidents not requiring independent investigation)60 working days from the date the incident is notified.Grade 2 (requiring independent investigation such as Homicide Investigations) –Internal investigation should be completed within 60 working days from the date ofthe incident. Where an independent investigation is commissioned this should becompleted within 26 weeks from the date of commissioning.14. Serious incidents should only be closed on STEIS following the receipt of a robustinvestigation report that has been generated following a full root cause analysis. Asa minimum, reports should include:root cause(s);lessons learned;have a time-bound action plan.15. Serious incidents can be closed by the Commissioning PCT or the SHA before thecompletion of an action plan if assurance is received of ongoing monitoring ofimplementation. The exception to this is grade 2 incidents where an independentinvestigation has taken place. In these cases, the Commissioning PCT and the SHAincident management policy 2011 with SUI v3 FINAL 45/51