Incident reporting policy - Homerton University Hospital

More documents

Recommendations

Info

They refer serious incident investigation reports to the Clinical Board when their findings may beconsidered to have significant trust wide implications, have significant resource implications, thefindings/recommendations may be deemed controversial or when there are serious behavioural problems.Clinical incidents, trends or concerns are escalated to the Clinical Governance Committee.14.3 Clinical Governance CommitteeThe role of the Clinical Governance Committee is to assure the Board of Directors that the Hospital iscontinually monitoring the safety and quality of clinical care, implementing appropriate controls to ensurethat this is maintained and addressing significant clinical risks. The committee will receive and review amonthly running summary of reported clinical incidents. This will focus primarily on numbers and trends,but will highlight significant incidents, for example where a patient has come to harm.The Clinical Governance Committee will report on a quarterly basis to the Risk Committee and whennecessary to Clinical Board.14.4 Health & Safety CommitteeMeets Quarterly. A Trust wide summary of reported non-clinical incidents is provided for perusal by thisCommittee to assess trends and make appropriate recommendations for further action or more detailedmonitoring.14.5 Risk CommitteeIt is the role of the Risk Committee to review all risks to the Organisation, Clinical / Non Clinical / Financial.The group receives regular reports from each of this „Risk areas‟ and reviews both the Risk Register andthe Board Assurance Framework.14.6 Trust Board of DirectorsA summary report of incidents is produced for the Board on an annual basis for information. This issupplemented by quarterly reports to the Risk Committee and Clinical Governance and ModernisationCommittee, the minutes of which are provided to as information to the Board of Directors.15.0 Incident Grading & Investigation Procedures15.1 Grading of IncidentsIncidents are graded according to the actual impact on the safety of person involved, and the potentialfuture risk to the Trust after corrective action has been put in place using the Trust‟s Risk Scoring Matrix(See Appendix 1).The severity level of an incident must be decided on the actual harm to the person affected as a resultof the incident.Incident severity is ranked from 1 to 5 as follows:Level 1Level 2Level 3Level 4Level 5Incident is considered Insignificant or Negligible requiring no intervention or treatment, ortime off from workMinor intervention requiring time off work for >3 days, increase in hospital stay by 1-3 daysModerate requiring professional intervention, time off work for 4-14 days, length of stay inhospital increase by 4-15 days, RIDDOR reportable or impacts on a small number ofpatientsMajor leading to long-term disability or incapacity, time off work >14 days, increasedhospital stay >15 days, or mis-management of patient care with long term effectsCatastrophic incident leading to death, permanent injuries or health effects and whichimpacts on a large number of patients. Thresholds depend on the circumstances andnature of the type of incident or hazard.(See Guide on Reporting Incidents)With the support of the appropriate Assistant General Manager for Quality and Risk or Divisional ClinicalPage 12 of 47
Risk Manager the Ward / Department Manager in charge of the incident location will review and grade allincidents. The Clinical and Non-Clinical Risk Manager(s) are also available to advice and support with thisincident grading.Incidents relating to relating to actual or potential breaches of confidentiality involving person identifiabledata (P.I.D), including data loss should have grading adjusted as per the scoring matrix in Appendix 1 todetermine the impact on the organisation and whether the incident constitutes reporting as a SeriousUntoward Incident.15.2 Investigation ProceduresIt is unrealistic to suggest that all incidents should be investigated to the same degree, or at the same levelwithin the Trust. Furthermore the outcome of an incident, including a "near miss", is often a poor indicatorof the level of investigation required.For all investigation levels described in the next section, the following should be followed / included withinthe investigation process:• The Trust Accountable Officer for Controlled Drugs, who is the Consultant Nurse for MedicinesManagement, must be involved and be part of the investigation team for all incidents involvingControlled Drugs. This is a statutory requirement for such incidents. The scoring matrix todetermine level of investigation for Drug Administration Errors should be used for all such incidents• The Chief Pharmacists must be involved in the investigation of incidents graded as Red or SeriousUntoward Incidents that involve drugs (including Controlled Drugs).• A Root Cause Analysis must be undertaken on all hospital acquired full thickness pressure ulcers(Grade 3 & 4's) incidents.• A Root Cause Analysis must be undertaken on all inpatient falls resulting in a fracture/other seriousinjury.• A Root Cause Analysis must always be carried out in all cases where the patient (adult or child)was treated in any way at the Trust (inpatient, outpatients, A&E) and subsequently diesunexpectedly within the next 7 days. If the patient dies after 7 days there must be a discussion withthe relevant clinicians and Trust executive team to determine whether an RCA is required.• All identified infections of hospital acquired Methicillin-resistant Staphylococcus Aureus (MRSA)and Colostrium Difficile (C. Diff) should be investigated using a specific MRSA or C. Diff RootCause Analysis approach. These are usually escalated as a Serious Untoward Incident. Furtherdetail can be provided by the Trust Nurse Consultant for Infection Control.• Midwifery Incidents – A supervisor of midwives should be involved in midwifery incidents with aconsequence score of 3 and above.15.3 Levels of InvestigationThe Clinical Risk and Non-Clinical Risk Managers(s) are available to advise and support with the processof investigation. This should be used as a guide only, only an executive director can make the finaldecision as to whether an incident is declared as an SUI.All SUIs should be investigated using Root Cause Analysis (RCA) methodology. For further information ofthe different level of investigation for SUIs please see 22.0. Root Cause Analysis e-learning programme isavailable on National Patient Safety Agency‟s website atwww.npsa.nhs.uk/health/resources/root_cause_analysis.Level of Incident Process Investigation Investigation TeamLeadRed IncidentsMajor / CatastrophicIncidents with a consequence score • of 4 or 5 Executive • Director Executive Director(Red) should be escalated to be consideredas a serious untoward incident and ifdeclared Serious Untoward Incidents (SUIs),should be escalated via the SUI proceduredetailed at Section 8.0. If a decision is taken• Senior / Service Manager .• A member of staff trained inRoot Cause Analysis (RCA)[ideally should not be fromthe service / departmentPage 13 of 47
Page 3: 1.0 Version ControlVersion Date Aut
Page 6 and 7: 6.0 Policy Definitions6.1 Adverse I
Page 8 and 9: The person in charge at the time of
Page 10 and 11: • Review sessions throughout the
Page 14 and 15: Level of Incident Process Investiga
Page 16 and 17: 17.3 Communication with StaffIt wil
Page 18 and 19: Trust‟s Raising Concerns at Work
Page 20 and 21: o action or lack of action by a mem
Page 22 and 23: In the event of a suspected SUI it
Page 24 and 25: managers determine how staff can be
Page 26 and 27: In cases where there may be legal i
Page 28 and 29: Appendix 1: Incident Risk Assessmen
Page 30 and 31: Table 2 Likelihood score (L)What is
Page 32 and 33: Community• Unplanned homebirth•
Page 34 and 35: Appendix 4: Reporting to External A
Page 36 and 37: Appendix 5: Reportable injuries or
Page 38 and 39: Appendix 6MEMORANDUM OF UNDERSTANDI
Page 40 and 41: Appendix 8: Infection Control Serio
Page 42 and 43: Appendix 10 - 24 Hour Meeting Agend
Page 44 and 45: Equalities Impact AssessmentThis ch
Page 46 and 47: Policy Submission FormPolicy Submis

Incident reporting policy - Homerton University Hospital

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?