Incident reporting policy - Homerton University Hospital
Incident reporting policy - Homerton University Hospital 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
Senior staff (Ward/Department Manager or similar) from the clinical/non clinical area where theincident happened – with a chronology of events as they are currently known.Head of Service/Clinical Lead/MatronSenior NurseClinical DirectorGeneral ManagerClinical Risk Manager/Non Clinical Risk Manager - will take notes of meetingStaff involved in the incident can be invited to attend.22.9 Declaration of a Serious Untoward IncidentAny incident that has the potential to be classed as an SUI should be escalated to an Executive Director inhours and to the on-call Director out of hours. In all cases the final decision whether to classify an incident asa SUI rests with an Executive Director. In case of clinical incidents the decision will be taken in consultationwith at least one of the following: Chief Executive, Deputy Chief Executive, Medical Director, Chief Nurse.The decision will be made at the 24 hour meeting and confirmed in the notes of the meeting which will be sentto the Head of Governance to ensure the Strategic Executive Information System (STEIS) database isupdated with the correct information. The PCT will be informed of the SUI via STEIS.Once an SUI had been reported to STEIS the Head of Governance must inform (by e-mail) the ChiefExecutive, Chief Nurse, Medical Director, Clinical Risk Manager and relevant Clinical Director, GeneralManager and Head of Nursing in the Division.22.10 Serious Incidents not reported outside the TrustSerious incidents that are not declared as SUIs and reported to the Strategic Health Authority and the PCTmay still require root cause analysis investigation. The actions listed below must be taken for any seriousincident investigation (SII) whether reported to the SHA or not.22.11 Role of the Executive Director with responsibility for risk or designated Executive DirectorFor SUIs of a clinical nature the relevant Executive Director will normally be the Medical Director or the ChiefNurse.Following the declaration of an SUI the relevant Executive Director is responsible for:- ensuring the patient(s)/ relative(s) have been/are informed of the incident and that an investigationis underway- ensuring that other parties and external organisations are informed where necessary. Wheremedical trainees are involved, the Director of Medical Education must be advised immediately.- deciding, in discussion with the Executive Team, whether a rapid response help line needs to beset up- arranging for the incident to be investigated via the 24 hour meeting- reviewing the SUI report and ensuring that this is presented to the Patient Safety Committee- Ensuring staff involved receive feedback once the investigation is complete- Ensuring that the patient/relatives receive feedback once the investigation is complete and thereport ratified by the Patient Safety Committee22.12 Support for staff involved in SUIsMembers of staff involved in an SUI can suffer significant emotional trauma and distress particularly if apatient has been harmed. Staff must be appropriately supported by their line manager and Employee HealthManagement Services. To prevent unnecessary and potentially damaging removal of staff from the workplace, the National Patient Safety Agency (NPSA) incident decision tree has been developed to helpPage 23 of 47
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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
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