Incident reporting policy - Homerton University Hospital

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