Incident reporting policy - Homerton University Hospital
Incident reporting policy - Homerton University Hospital Incident reporting policy - Homerton University Hospital
Appendix 10 – 24 Hour Meeting Agenda1. Review of incident with outline chronologyAgenda for 24 Hour SUI Meeting2. List people involved (name and position: this information will not be circulated)3. Immediate safety actions taken at time of incident/notable practice4. Status of Patient / information given to patient or relatives5. Service / Care delivery problems immediately apparent/6. Confirm actions, due date and responsible personY/N/N/Ai. 24 Hour Meeting only Named person to lead investigation:Level ofInvestigationRequiredii.iii.iv.Any additions to the standard ToRAgreed scope of investigationConcise (Internal)Comprehensive(report to NHS London)External investigator to beappointedWho will collect staff statements for investigation?NB: see over for Standard T of RWho will retain/arrange for copies of the patient‟shealth care record?Have patient/relatives been givenBeingOpeninformation?What further information needs to begiven?Who will support staff following incident andduring investigation?Is it necessary to isolate equipment?By whom:By whom:If yes, has this been done and whereis equipmentHas a post mortem been requested?Do thefollowingneed to beinformedThe CoronerThe Communications DeptThe Legal Services DeptPOVA / ISAOther agencies i.e. HSE, MHRAIs a helpline or look back going to be required?Is a follow up meeting required?If yes, who will organiseIf yesWhen should this beWho will arrangeWho will be invitedPage 42 of 47
Standard Terms of Reference for SUI investigationThe following are the standard T of R for SUI investigations at Homerton University NHS Foundation Trust. Theseshould be reviewed at the 24 meeting to establish if they address the criteria for the proposed investigation or iffurther objectives need to be added.To establish the sequence of events that led to the above incidentTo establish whether failings occurred in care and/or treatmentTo identify learning opportunities and improvementsTo formulate realistic recommendations for practice that will address the root causes of theincidentTo present the key findings in a report that will serve as a record of the investigationScope of the InvestigationThe scope of the investigation must be established at the 24 hour meeting. This includes:What length of time will be covered by the investigation (e.g. this admission, previous admissions, specificperiod of time)Which services will be included in the investigation (including any external agencies)Will the investigation examine issues other than those immediately referred to at the time of reporting.Created by Clinical Risk Advisors Barts and The London NHS TrustPage 43 of 47
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Appendix 10 – 24 Hour Meeting Agenda1. Review of incident with outline chronologyAgenda for 24 Hour SUI Meeting2. List people involved (name and position: this information will not be circulated)3. Immediate safety actions taken at time of incident/notable practice4. Status of Patient / information given to patient or relatives5. Service / Care delivery problems immediately apparent/6. Confirm actions, due date and responsible personY/N/N/Ai. 24 Hour Meeting only Named person to lead investigation:Level ofInvestigationRequiredii.iii.iv.Any additions to the standard ToRAgreed scope of investigationConcise (Internal)Comprehensive(report to NHS London)External investigator to beappointedWho will collect staff statements for investigation?NB: see over for Standard T of RWho will retain/arrange for copies of the patient‟shealth care record?Have patient/relatives been givenBeingOpeninformation?What further information needs to begiven?Who will support staff following incident andduring investigation?Is it necessary to isolate equipment?By whom:By whom:If yes, has this been done and whereis equipmentHas a post mortem been requested?Do thefollowingneed to beinformedThe CoronerThe Communications DeptThe Legal Services DeptPOVA / ISAOther agencies i.e. HSE, MHRAIs a helpline or look back going to be required?Is a follow up meeting required?If yes, who will organiseIf yesWhen should this beWho will arrangeWho will be invitedPage 42 of 47
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