Risk Management Annual Report - August 2009 ... - NHS Lanarkshire

Risk Management
Annual Report
2008 – 09
The rating of an incident determines the subsequent communication and investigation
levels. Between December 2007 – November 2008, 10% of incidents were rated
with the remaining 90% without rating this may result in poor communications and
investigation levels.
ACTION:
In future, rating will become a mandatory field with the member of staff
recording the incident rating it. This action is in line with the National Patient
Safety Agency (NPSA) guidance and was agreed by the Risk Management
Guidance SLWG. To ensure staff are able to rate the incident, all staff will receive
an aide memoir demonstrating the process. In addition, there will be links from
the incident form to rating guidance.
The incident will only be added to the main database once there is agreement
between the person recording, rand rating the incident and the verifier.
More than a third of incidents remain in the holding area each month, therefore
remaining unverified. One possible outcome of is that incidents are identified but
may not be investigated and timely remedial action taken as a result.
ACTION:
The Risk Management Guidance (SLWG) has agreed a maximum period of 5
working days for incidents to remain in the holding area. The timescales will be
monitored by line managers and governance structures.
Template reports are currently being designed which reflect the generic incident reports
developed by the Risk Management SLWG. This will support committees to provide
assurances on risk management.
In addition to incident management template reports, the system is being configured
to produce reports which will allow NHSL to monitor the risk management key
performance indicators developed by the Risk Management SLWG.
Risks Register
Currently risks are placed on registers in the Datix main application. The Risk
Management Department is currently configuring the web based module so that in
future risk registers will be entered and managed using the web interface.
The Risk Management SLWG agreed a risk escalation process including questions to
be answered at each escalation stage; these have been incorporated into the web Risk
Form. This will allow NHSL to be reassured that risks are being managed at the correct
level in the organisation.
Complaints
Complaints across NHSL are managed through the complaints module. Recent changes
to ISD dataset requirements have resulted in an upgrade to the system to version 9.3a.
This will provide ISD with the revised dataset information from mid January 2009.
Performance for Year 2008 – 09
8