Incident reporting policy - Homerton University Hospital
Incident reporting policy - Homerton University Hospital Incident reporting policy - Homerton University Hospital
o action or lack of action by a member of the Trust‟s staff, employees of other agencies orcontractorso Trust responsible Meticillin Resistant Staphylococcus aureaus (MRSA) bacteraemias(regardless of outcome) and Clostridium difficile related deaths (pt 1 of death certificate)• Serious damage to NHS property e.g. through fire, flood or criminal activity etc;• Major public health risk occurs e.g. outbreak of infection such as salmonella or legionella, radiationincidents;• Large scale theft, confidentiality breach or fraud has occurred, or major litigation is expected• Incidents affecting large numbers of people;• Any event likely to lead to significant legal, media or other interests if not properly managed and/ormay result in loss of the Trust's reputation, services or assets.• Child deaths or serious injuries that have elements of child abuse or neglect or are press-worthy, orwhere there is poor clinical management would constitute an SUI. Investigation of such incidentsshould be carried out in line with this policy but with specific reference to the Trust SafeguardingChildren Policy and Trust procedure for the management of child deaths.Specific definitions have been defined for incidents related to infection control see Appendix 8.22.5 The following 4 types of incidents should be referred to alternative investigation processes for resolutione.g. Human Resources, professional regulatory body, police etc• Events thought to be the result of a criminal act by care provider/staff• Purposeful (malicious) unsafe acts by care provider /staff intending to cause harm• Acts related to substance abuse by care provider/staff• Events involving suspected patient abuse of any kind.22.6 SUI Accountability, responsibility and compliance22.6.1 Chief ExecutiveThe Chief Executive must ensure that the Trust has a robust system in place to manage serious untowardincidents and that staff are skilled to carry out their responsibilities.22.6.2 Medical Director and the Chief Nurse and Director Governance (referred to as the Chief Nurse inthe remainder of this document)The Medical Director and Chief Nurse have joint responsibility for Clinical Governance within the Trust.The Chief Executive has delegated responsibility for the strategic development and implementation ofpolicies and procedures relating to serious untoward incident and near miss reporting to the Chief Nurse,as outlined in the policy, namely:• The Chief Nurse is responsible for confirming action or giving further advice to the senior/servicemanager following identification or suspicion of a serious untoward incident.• The Chief Nurse will ensure that the senior/service managers are fully prepared to initiate incidentreports, to establish facts, revise systems and procedures and take other action that may bedeemed necessary, including the audit of action plans.• The Chief Nurse will liaise with the Executive team to determine whether other parties should beinformed, and will undertake further action as agreed.• The Chief Nurse will report to the Clinical Board and the Board of Directors monthly to reviewserious untoward incidents and progress of the action taken.• The Chief Nurse will discuss with the Chief Executive and the Clinical Board matters immediatelyarising from the incident and follow-up action to be taken both without delay and when theinvestigation is concluded.22.6.3 Executive DirectorsExecutive Directors are responsible for implementing/overseeing the following key aspects of the reportingand investigation of SUIs. They must;Page 20 of 47
• Assess the environment and risks to patients and staff following an SUI ensuring appropriateimmediate action to minimize risk is taken.• Immediately notify the Risk Management Department when an SUI is suspected.• Ensure staff involved complete statements within 1 week of the incident (See Policy on Writing aWitness Statement).• Submit formal reports, including progress reports to the Chief Nurse in respect of the factssurrounding any untoward incident as requested.• Implement the agreed action plan to minimize the risk of recurrence.22.6.4 Clinical Risk/Non Clinical Risk ManagerThe risk managers‟ responsibility is the updating of this policy at a minimum every 3 years or sooner ifnecessary. To train staff in root cause analysis in order that they can undertake SUI investigations. Tosupport staff undertaking SUI investigations, particularly in relation to report writing and to ensure thereports are presented at the Patient Safety Committee and action plans followed up.The Clinical Risk Manager will maintain a database of all SUIs in order to monitor progress of theinvestigation and action plans.22.6.5 Managers trained in Root Cause AnalysisThese managers have a responsibility to undertake a full investigation of the incident (either alone or aspart of a team) using root cause analysis, if requested to do so by the Chief Nurse.22.6.6 The Press OfficerThe Press Officer is responsible for handling any likely media interest resulting from any SUI liaisingclosely with the Chief Executive and, where necessary, the Strategic Health Authority and the PrimaryCare Trust (Section 17.7 of Incident Reporting Policy and Media Reporting Policy).22.6.7 ManagersManagers, including Ward managers, Departmental Managers and Team Leaders are responsible for:• Providing the supportive environment required to facilitate untoward incident reporting.• Ensuring staff are aware of this policy and that new staff are made aware of the policy on induction.• Keeping staff up to date about any changes within the policy.• Ensuring staff adhere to the reporting procedures outlined in this policy.• Ensuring staff report any untoward incident immediately to the most senior person in thedepartment.• Supporting staff, patients and carers/relatives through any investigation and arrangingcounselling/on-going support for any members of staff who may be suffering emotional trauma as aresult of being involved in an SUI.• Undertaking local risk assessments.22.6.8 All EmployeesAll employees have a responsibility to report untoward incidents and near misses to their line manager,Senior Manager or Clinical Site Manager immediately to ensure that the SUI policy is initiated.All employees are responsible for co-operating in the investigation process. It is expected that uponrequest to attend an interview or to submit a statement staff will fully co-operate and provide a full accountof events. Requests for statements should be responded to within 7 days from the date of initial request.(See Policy for Writing a Witness Statement).22.7 Organisational arrangements for the reporting serious untoward incidentsPage 21 of 47
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o action or lack of action by a member of the Trust‟s staff, employees of other agencies orcontractorso Trust responsible Meticillin Resistant Staphylococcus aureaus (MRSA) bacteraemias(regardless of outcome) and Clostridium difficile related deaths (pt 1 of death certificate)• Serious damage to NHS property e.g. through fire, flood or criminal activity etc;• Major public health risk occurs e.g. outbreak of infection such as salmonella or legionella, radiationincidents;• Large scale theft, confidentiality breach or fraud has occurred, or major litigation is expected• <strong>Incident</strong>s affecting large numbers of people;• Any event likely to lead to significant legal, media or other interests if not properly managed and/ormay result in loss of the Trust's reputation, services or assets.• Child deaths or serious injuries that have elements of child abuse or neglect or are press-worthy, orwhere there is poor clinical management would constitute an SUI. Investigation of such incidentsshould be carried out in line with this <strong>policy</strong> but with specific reference to the Trust SafeguardingChildren Policy and Trust procedure for the management of child deaths.Specific definitions have been defined for incidents related to infection control see Appendix 8.22.5 The following 4 types of incidents should be referred to alternative investigation processes for resolutione.g. Human Resources, professional regulatory body, police etc• Events thought to be the result of a criminal act by care provider/staff• Purposeful (malicious) unsafe acts by care provider /staff intending to cause harm• Acts related to substance abuse by care provider/staff• Events involving suspected patient abuse of any kind.22.6 SUI Accountability, responsibility and compliance22.6.1 Chief ExecutiveThe Chief Executive must ensure that the Trust has a robust system in place to manage serious untowardincidents and that staff are skilled to carry out their responsibilities.22.6.2 Medical Director and the Chief Nurse and Director Governance (referred to as the Chief Nurse inthe remainder of this document)The Medical Director and Chief Nurse have joint responsibility for Clinical Governance within the Trust.The Chief Executive has delegated responsibility for the strategic development and implementation ofpolicies and procedures relating to serious untoward incident and near miss <strong>reporting</strong> to the Chief Nurse,as outlined in the <strong>policy</strong>, namely:• The Chief Nurse is responsible for confirming action or giving further advice to the senior/servicemanager following identification or suspicion of a serious untoward incident.• The Chief Nurse will ensure that the senior/service managers are fully prepared to initiate incidentreports, to establish facts, revise systems and procedures and take other action that may bedeemed necessary, including the audit of action plans.• The Chief Nurse will liaise with the Executive team to determine whether other parties should beinformed, and will undertake further action as agreed.• The Chief Nurse will report to the Clinical Board and the Board of Directors monthly to reviewserious untoward incidents and progress of the action taken.• The Chief Nurse will discuss with the Chief Executive and the Clinical Board matters immediatelyarising from the incident and follow-up action to be taken both without delay and when theinvestigation is concluded.22.6.3 Executive DirectorsExecutive Directors are responsible for implementing/overseeing the following key aspects of the <strong>reporting</strong>and investigation of SUIs. They must;Page 20 of 47
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