Incident reporting policy - Homerton University Hospital

In the event of a suspected SUI it is vital that there is no delay in notifying the relevant managers so that thenecessary action can be taken and documentedWorking hours 09:00 -17:00During standard working hours it is the responsibility of the most senior person present at the incidentto inform the local manager, normally the ward sister/Department manager, who will inform theappropriate person in the Directorate management team (e.g. Head of Nursing, General Manager,Clinical Director). The Senior Manager on call, Risk Management and an executive Director must alsobe informed.An incident report must be completed on Datix. Details of the incident should then be discussed assoon as possible with the Risk Management Department staff, who will notify the appropriateExecutive Director. In cases where there is doubt as to whether an incident is an SUI notification muststill take place.Out of Hours 17:00 – 09:00The most senior person present at the event must contact the Clinical Site Manger (CSM). It is theresponsibility of the CSM to notify the relevant Senior Manager on-call and for making sure that anincident report is completed on Datix.The Senior Manager On-Call is responsible for contacting the Executive Director On-Call as soon aspossible to notify them; of the incident, what action has been already been taken and to discuss theneed for any further action.The Senior Manager (or Senior Manager On-Call if out of hours) must prepare a written summary of theprecise timings of events, including any immediate action taken and any instructions given. This briefing mustbe emailed to the Risk Management Department the following day.22.8 Actions and documentationAll staff involved in the incident in whatever capacity (including staff called for help after the incidentoccurred both on Trust premises and those on call) must write a statement of their involvement. (SeePolicy for Writing a Witness Statement)The person in charge of the department where the incident happened/Clinical Site Manager must ensurethat:• Where applicable, the incident is documented in the patient‟s healthcare record.• An incident report is completed on Datix.• Any equipment involved is isolated from use, the settings and recordings to remain unaltered.• All documentation is secured (Case notes, X-Rays, ECGs, CTGs…)• Arrange for the health care records to be copied if they are required for ongoing care.• Any relevant photographic evidence is collected and diagrams drawn.• Make a list of all those involved, including witnesses, and ensure they write statements.22.8.1 24 Hour MeetingThe Executive in charge (whether on call or in hours) that has been informed of the incident is responsiblefor arranging a meeting of the relevant staff within 24 hours of the incident being reported.This meeting is to establish known facts, establish whether the incident is an SUI or not and what actionsneed to be taken.If investigation is required the level of investigation and the terms of reference will be established at the 24hour meeting.22.8.2 The agenda for the 24 hour meeting and standard terms of reference are at Appendix 1022.8.3 The following staff must be invited to attend the 24 hour meeting:Chair – one of the Trust executive directorsPage 22 of 47