Incident reporting policy - Homerton University Hospital
Incident reporting policy - Homerton University Hospital Incident reporting policy - Homerton University Hospital
Appendix 1: Incident Risk AssessmentManagement must review incidents to determine the best course of action to eliminate, reduce and control risks.There will always be some degree of risk. However, when the level of risk is controlled and the level of injury islow, the impact on the Trust will also be low, so the level of risk is acceptable. Risk assessment is the process forassessing and prioritising clinical and non-clinical risks. It can also help managers recognise the incidents theyshould report to senior managers and when they need specialist help to prevent incidents recurring.Table 1 Consequence scoresChoose the most appropriate domain for the identified risk from the left hand side of the table Then work along thecolumns in same row to assess the severity of the risk on the scale of 1 to 5 to determine the consequence score,which is the number given at the top of the column.Consequence score (severity levels) and examples of descriptorsDomainsImpact on thesafety ofpatients, staffor public(physical/psychologicalharm)1 2 3 4 5None/InsignificantNegligibleMinimal injuryrequiring no/minimalintervention ortreatment.No time off workMinor Moderate Major CatastrophicMinor injury orillness, requiringminor interventionRequiring time offwork for >3 daysIncrease in length ofhospital stay by 1-3daysModeraterequiringprofessionalinterventioninjuryRequiring time offwork for 4-14 daysIncrease in length ofhospital stay by 4-15daysRIDDOR/agencyreportable incidentMajor injury leadingto long-termincapacity/disabilityRequiring time offwork for >14 daysIncrease in length ofhospital stay by >15daysMismanagement ofpatient care withlong-term effectsIncident leadingdeathtoMultiple permanentinjuriesorirreversible healtheffectsAn event whichimpacts on a largenumber of patientsAn event whichimpacts on a smallnumber of patientsQuality/complaints/auditPeripheral elementof treatment orservice suboptimalInformalcomplaint/inquiryOverall treatment orservice suboptimalFormal(stage 1)Local resolutioncomplaintSingle failure tomeet internalstandardsMinor implicationsfor patient safety ifunresolvedReducedperformance rating ifunresolvedTreatment or servicehas significantlyreducedeffectivenessFormal complaint(stage 2) complaintLocal resolution(with potential to goto independentreview)Repeated failure tomeet internalstandardsMajor patient safetyimplications iffindings are notacted onNon-compliancewith nationalstandards withsignificant risk topatientsifunresolvedMultiple complaints/independent reviewLowratingCritical reportperformanceTotally unacceptablelevel or quality oftreatment/serviceGross failure ofpatient safety iffindings not actedonInquest/ombudsmaninquiryGross failure tomeet nationalstandardsPage 28 of 47
Humanresources/organisationaldevelopment/staffing/competenceStatutory duty/inspectionsShort-term lowstaffing level thattemporarily reducesservice quality (< 1day)No or minimalimpact or breech ofguidance/ statutorydutyLow staffing levelthat reduces theservice qualityBreech of statutorylegislationReducedperformance rating ifunresolvedLate delivery of keyobjective/ servicedue to lack of staffUnsafe staffing levelor competence (>1day)Low staff moralePoorstaffattendance formandatory/keytrainingSingle breech instatutory dutyChallenging externalrecommendations/improvement noticeUncertain delivery ofkeyobjective/servicedue to lack of staffUnsafe staffing levelor competence (>5days)Loss of key staffVery low staffmoraleNo staff attendingmandatory/ keytrainingEnforcement actionMultiple breeches instatutory dutyImprovementnoticesNon-delivery of keyobjective/servicedue to lack of staffOngoing unsafestaffing levels orcompetenceLoss of several keystaffNo staff attendingmandatory training/key training on anongoing basisMultiple breeches instatutory dutyProsecutionComplete systemschange requiredLowratingperformanceZeroratingperformanceAdversepublicity/reputationRumoursPotential for publicconcernLocal mediacoverage –short-term reductionin public confidenceElements of publicexpectation notbeing metLocal mediacoverage –long-term reductionin public confidenceCritical reportNational mediacoverage with 3days service wellbelow reasonablepublic expectation.MP concerned(questions in theHouse)Businessobjectives/projectsFinanceincludingclaimsService/business interruptionEnvironmentalimpactInsignificant costincrease/ scheduleslippageSmall loss Risk ofclaim remoteLoss/interruption of>1 hourMinimal or noimpact on theenvironment8 hoursMinor impact onenvironment5–10 per cent overproject budgetSchedule slippageLoss of 0.25–0.5 percent of budgetClaim(s) between£10,000 and£100,000Loss/interruption of>1 dayModerate impact onenvironmentNon-compliancewith national 10–25per cent over projectbudgetSchedule slippageKey objectives notmetUncertain delivery ofkey objective/Lossof 0.5–1.0 per centof budgetClaim(s) between£100,000 and £1millionPurchasers failing topay on timeLoss/interruption of>1 weekMajor impact onenvironmentTotal loss of publicconfidenceIncident leading >25per cent over projectbudgetSchedule slippageKey objectives notmetNon-delivery of keyobjective/ Loss of >1per cent of budgetFailure to meetspecification/slippageLoss of contract /payment by resultsClaim(s) >£1 millionPermanent loss ofservice or facilityCatastrophic impacton environmentPage 29 of 47
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- Page 8 and 9: The person in charge at the time of
- Page 10 and 11: • Review sessions throughout the
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- Page 14 and 15: Level of Incident Process Investiga
- Page 16 and 17: 17.3 Communication with StaffIt wil
- Page 18 and 19: Trust‟s Raising Concerns at Work
- Page 20 and 21: o action or lack of action by a mem
- Page 22 and 23: In the event of a suspected SUI it
- Page 24 and 25: managers determine how staff can be
- Page 26 and 27: In cases where there may be legal i
- Page 30 and 31: Table 2 Likelihood score (L)What is
- Page 32 and 33: Community• Unplanned homebirth•
- Page 34 and 35: Appendix 4: Reporting to External A
- Page 36 and 37: Appendix 5: Reportable injuries or
- Page 38 and 39: Appendix 6MEMORANDUM OF UNDERSTANDI
- Page 40 and 41: Appendix 8: Infection Control Serio
- Page 42 and 43: Appendix 10 - 24 Hour Meeting Agend
- Page 44 and 45: Equalities Impact AssessmentThis ch
- Page 46 and 47: Policy Submission FormPolicy Submis
Humanresources/organisationaldevelopment/staffing/competenceStatutory duty/inspectionsShort-term lowstaffing level thattemporarily reducesservice quality (< 1day)No or minimalimpact or breech ofguidance/ statutorydutyLow staffing levelthat reduces theservice qualityBreech of statutorylegislationReducedperformance rating ifunresolvedLate delivery of keyobjective/ servicedue to lack of staffUnsafe staffing levelor competence (>1day)Low staff moralePoorstaffattendance formandatory/keytrainingSingle breech instatutory dutyChallenging externalrecommendations/improvement noticeUncertain delivery ofkeyobjective/servicedue to lack of staffUnsafe staffing levelor competence (>5days)Loss of key staffVery low staffmoraleNo staff attendingmandatory/ keytrainingEnforcement actionMultiple breeches instatutory dutyImprovementnoticesNon-delivery of keyobjective/servicedue to lack of staffOngoing unsafestaffing levels orcompetenceLoss of several keystaffNo staff attendingmandatory training/key training on anongoing basisMultiple breeches instatutory dutyProsecutionComplete systemschange requiredLowratingperformanceZeroratingperformanceAdversepublicity/reputationRumoursPotential for publicconcernLocal mediacoverage –short-term reductionin public confidenceElements of publicexpectation notbeing metLocal mediacoverage –long-term reductionin public confidenceCritical reportNational mediacoverage with 3days service wellbelow reasonablepublic expectation.MP concerned(questions in theHouse)Businessobjectives/projectsFinanceincludingclaimsService/business interruptionEnvironmentalimpactInsignificant costincrease/ scheduleslippageSmall loss Risk ofclaim remoteLoss/interruption of>1 hourMinimal or noimpact on theenvironment8 hoursMinor impact onenvironment5–10 per cent overproject budgetSchedule slippageLoss of 0.25–0.5 percent of budgetClaim(s) between£10,000 and£100,000Loss/interruption of>1 dayModerate impact onenvironmentNon-compliancewith national 10–25per cent over projectbudgetSchedule slippageKey objectives notmetUncertain delivery ofkey objective/Lossof 0.5–1.0 per centof budgetClaim(s) between£100,000 and £1millionPurchasers failing topay on timeLoss/interruption of>1 weekMajor impact onenvironmentTotal loss of publicconfidence<strong>Incident</strong> leading >25per cent over projectbudgetSchedule slippageKey objectives notmetNon-delivery of keyobjective/ Loss of >1per cent of budgetFailure to meetspecification/slippageLoss of contract /payment by resultsClaim(s) >£1 millionPermanent loss ofservice or facilityCatastrophic impacton environmentPage 29 of 47
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