Incident reporting policy - Homerton University Hospital
Incident reporting policy - Homerton University Hospital Incident reporting policy - Homerton University Hospital
6.0 Policy Definitions6.1 Adverse Incident: Is defined as an event or circumstance that leads to either unintended or intendedharm, loss or damage to a patient / staff / general public / equipment / building, which may be clinical ornon-clinical (see 4.6 below for further definition and examples of clinical and non-clinical incidents).6.2 Near Miss: Is defined as an event or circumstance, which could have but did not result in harm to patient/staff / general public / equipment / building. This may be clinical or non-clinical where no immediate harm,loss or damage was suffered, but if not detected could have led to an adverse incident. It is important torecord/assess these incidents so they can be investigated and any preventative measures taken.6.3 Harm: Is defined as injury (physical or psychological), disease, disability or death. In the case of incidentsarising during patient care, harm can be considered „unexpected‟ if it is not related to the natural cause ofthe patient‟s illness or underlying condition. Adverse outcomes related to natural course of illness or propertreatment in accordance with accepted clinical standards are therefore NOT classed as clinical incidents.6.4 Consequence: Is defined as the effect, result, or outcome of an incident. This is classified asCatastrophic, Major, Moderate, Minor, Insignificant / None. Refer to Appendix 1 for categorisation,description and scoring. This table is used to assist with the identification of the consequence of anincident.6.5 Clinical and Non-clinical Adverse EventsA clinical incident is any untoward event or near miss that involves a patient e.g. drug errors,patients falling, patient going missing (rather than environmental issues i.e. food, heating etc)The following list demonstrates the range of events the Trust are obliged to record, some of which may beimmediately evident while some may not be. This list should be used as a further guide as to what shouldbe reported:NPSA Never Events 1• Wrong site surgery• Retained instrument post-operation• Wrong route administration of chemotherapy• Misplaced naso or orogastric tube not detected prior to use• Inpatient suicide using non-collapsible rails• Intravenous administration of mis-selected concentrated potassium chlorideA non-clinical incident is an untoward event that involves any person (eg member of staff, visitors, voluntaryworkers, contractors etc). A non-clinical incident may be an accident or a near miss. Please note that there arelegal duties under RIDDOR that require you to report and record some work-related accidents by the quickestmeans possible. Please see Appendix 5 for further details on RIDDOR reportable incidents.For other examples of reportable incidents see Appendix 2.6.6 Serious Untoward Incident: Is defined as:“An accident or incident when a person to whom the organisation owes a duty of care0 2 suffers (or1The National Reporting and Learning System (NRLS) within the National Patient Safety Agency (NPSA) have identified a core list of„Never Events‟ which are serious, largely preventable patient safety incidents that should not occur if the available preventative measureshave been implemented. Implementation of a policy on Never Events was identified in High Quality Care for All: NHS Next Stage ReviewFinal Report as a key priority for the NHS in England.2Patient, member of staff (including those who work in the community), or member of the publicPage 6 of 47
probably has suffered) a serious injury, major permanent harm or unexpected death 3 in hospital,other health service premises or other premises where NHS care is provided”and/orAn accident or incident that is in itself sufficiently serious and could in normal circumstances leadto death, serious injury or major permanent harm even if in the case considered it did not.and/orAccidents or incidents (or series of them that accumulate or build up to form a more seriousproblem) which are likely to cause significant concern to staff or the public or may producesignificant legal or media interest.The process for the management of these events is covered by Serious Untoward Incident (SUI) Procedure at22.0 below.7.0. Incident Reporting Process7.1 This process guide identifies the action that should be taken in the event of an incident. This is designedto ensure that adverse incidents are dealt with promptly and effectively so that the risk of harm to staff,patients and visitors is minimised and appropriate follow-up action is taken. It is recognised that the verynature of adverse incidents will call for a degree of flexibility and initiative by the individuals involved whichcannot be defined in this procedure.7.2 This procedure should be implemented by the senior member of staff on duty in an area when an adverseincident or near miss occurs.7.3 Action to be taken on discovery of an incident or near missThe most senior member of staff on duty is responsible for ensuring, as appropriate.• The immediate safety and care of the people involved• That the area has been made as safe as possible. Staff should only act within their capabilities andshould not jeopardise their own or others safety.• That a senior manager has been informed• That the scene is preserved; the area or equipment involved is isolated and that there is nounauthorised entry to the area or tampering with the equipment if applicable.• The area or equipment is not re-used until authorised by a senior manager.• That, where possible, statements have been taken from witnesses. If this is not possible at the time,then the names and contact details of all witnesses should be recorded so that statements can beobtained later.• That an incident report form is completed electronically on Datix in accordance with these guidelines.7.4 In the event of a serious untoward incident, as defined above, the Trust‟s Serious Untoward Proceduremust be followed at 22.0.8.0 Reporting Adverse Incidents8.1 Adverse events and near misses must be reported as soon as reasonably possible, using the Trusts onlineDatix system which can be accessed via the Trust intranet homepage. This process should be used toreport any incident that takes place on Trust property and to Trust staff at locations outside of the Truste.g. in a patient‟s home. On-line reporting can also be used for any incidents that involve the businessactivities of the Trust in any shape or form.8.2 Completion of the form provides:Formal documentation of all incidentsManagers with the opportunity to investigate and implement remedial action wherever necessary.8.3 The following points should also be noted:3 An event which has resulted in an unanticipated death or harm not related to the natural cause of the patient illness/underlyingcondition/pregnancy/childbirth. To be declared as SUI an incident, as well as the actual harm, must have occurred. A causal link betweenincident and outcome does not need to be demonstrated (e.g. by post-mortem) but must be plausible or suspected.Page 7 of 47
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probably has suffered) a serious injury, major permanent harm or unexpected death 3 in hospital,other health service premises or other premises where NHS care is provided”and/orAn accident or incident that is in itself sufficiently serious and could in normal circumstances leadto death, serious injury or major permanent harm even if in the case considered it did not.and/orAccidents or incidents (or series of them that accumulate or build up to form a more seriousproblem) which are likely to cause significant concern to staff or the public or may producesignificant legal or media interest.The process for the management of these events is covered by Serious Untoward <strong>Incident</strong> (SUI) Procedure at22.0 below.7.0. <strong>Incident</strong> Reporting Process7.1 This process guide identifies the action that should be taken in the event of an incident. This is designedto ensure that adverse incidents are dealt with promptly and effectively so that the risk of harm to staff,patients and visitors is minimised and appropriate follow-up action is taken. It is recognised that the verynature of adverse incidents will call for a degree of flexibility and initiative by the individuals involved whichcannot be defined in this procedure.7.2 This procedure should be implemented by the senior member of staff on duty in an area when an adverseincident or near miss occurs.7.3 Action to be taken on discovery of an incident or near missThe most senior member of staff on duty is responsible for ensuring, as appropriate.• The immediate safety and care of the people involved• That the area has been made as safe as possible. Staff should only act within their capabilities andshould not jeopardise their own or others safety.• That a senior manager has been informed• That the scene is preserved; the area or equipment involved is isolated and that there is nounauthorised entry to the area or tampering with the equipment if applicable.• The area or equipment is not re-used until authorised by a senior manager.• That, where possible, statements have been taken from witnesses. If this is not possible at the time,then the names and contact details of all witnesses should be recorded so that statements can beobtained later.• That an incident report form is completed electronically on Datix in accordance with these guidelines.7.4 In the event of a serious untoward incident, as defined above, the Trust‟s Serious Untoward Proceduremust be followed at 22.0.8.0 Reporting Adverse <strong>Incident</strong>s8.1 Adverse events and near misses must be reported as soon as reasonably possible, using the Trusts onlineDatix system which can be accessed via the Trust intranet homepage. This process should be used toreport any incident that takes place on Trust property and to Trust staff at locations outside of the Truste.g. in a patient‟s home. On-line <strong>reporting</strong> can also be used for any incidents that involve the businessactivities of the Trust in any shape or form.8.2 Completion of the form provides:Formal documentation of all incidentsManagers with the opportunity to investigate and implement remedial action wherever necessary.8.3 The following points should also be noted:3 An event which has resulted in an unanticipated death or harm not related to the natural cause of the patient illness/underlyingcondition/pregnancy/childbirth. To be declared as SUI an incident, as well as the actual harm, must have occurred. A causal link betweenincident and outcome does not need to be demonstrated (e.g. by post-mortem) but must be plausible or suspected.Page 7 of 47
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