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Development and Ratification of a Policy, Protocol, Procedure or

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Development and Ratification of a Policy, Protocol, Procedure or ...

    Corporate Governance

    Incident Management

    Policy

    SWH-00020

Version: Version 1

    Job Title of Responsible Manager: Patient Safety Manager Job Title of Executive Sponsor: Medical Director

    Ward / Department: Trust wide

    Replacing Document: Incident Management Policy February 2004 Approving Committee / Group: Clinical Governance Committee Date Approved: 2008

    Date for Review: 2011

    Relevant Standard(s): SfBH C1a Safety and Standard 5:1, 5.5, 5.6 & 5.7

    NHSLA

    -1-

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    Incident Management Policy

    Table of Contents

    1. INTRODUCTION ........................................................................................................ 3 2. PURPOSE .................................................................................................................. 3 3. DEFINITIONS OF AN ADVERSE EVENT, NEAR MISS OR HAZARD ...................... 4 4. AUDIENCE ................................................................................................................. 5 5. RESPONSIBILITIES / DUTIES................................................................................... 5 6. PROCEDURAL REQUIREMENTS ............................................................................. 8 7. MONITORING COMPLIANCE AND EFFECTIVENESS ............................................ 9 8. AUTHOR(S) ................................................................................................................ 9 9. CONTRIBUTORS ....................................................................................................... 9 10. EQUALITY IMPACT ASSESSMENT TOOL............................................................... 9 11. REFERENCES ........................................................................................................... 9 APPENDIX A: ACTIONS AND RESPONSIBILITIES FOR ALL STAFF IN THE EVENT

    OF AN INCIDENT .............................................................................................................. 10 APPENDIX B INCIDENTS THAT SHOULD ALWAYS BE REPORTED (TRIGGER LIST)

     ........................................................................................................................................... 11 APPENDIX C NOTIFIABLE EXTERNAL AGENCIES .................................................... 12 APPENDIX D - WHAT IS REPORTABLE UNDER RIDDOR? .......................................... 13 APPENDIX E INCIDENT ASSESSMENT PROCESS ...................................................... 16 MONITORING COMPLIANCE WITH AND EFFECTIVENESS OF PROCEDURAL

    DOCUMENTS FORM ........................................................................................................ 18 DISSEMINATING PROCEDURAL DOCUMENT FORM ................................................... 19 APPROVING PROCEDURAL DOCUMENTS CHECKLIST .............................................. 20 Draft Version 1, April 2008 Page 2 of 20 Printed on 26/06/10

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    Incident Management Policy

1. Introduction

In the course of providing health care, events can occur which have or may have serious

    consequences for the Trust its service users, staff, and the public. South Warwickshire General Hospitals NHS Trust has a responsibility to make every effort to reduce the likelihood of repeat occurrences by investigating events, understanding their root causes and taking appropriate

    preventative action. In a service as large and complex as the NHS, things will sometimes go wrong.

    It is not sufficient, however, to learn and improve only when things go wrong. The learning from the investigation of an adverse event or near miss must be seen as a part of the Trust‟s broader strategy of organisational risk management. The Trust is committed to proactive risk management activity, in addition to the reactive process of incident management. This will enable it to identify and prevent many things that could go wrong as well as those that do.

    Promoting patient safety by reducing error is a key priority of the NHS. The National Patient Safety Agency (NPSA) was established in July 2001 to run a reporting system to record, analyse and learn

    from adverse events and near misses involving NHS patients. The NPSA ensures that lessons learnt

    in one part of the NHS are properly shared with the whole of the health service. The NPSA is keen to encourage a culture throughout the NHS where everyone involved in the safe delivery of health care

    is happy to report and discuss incidents.

    This policy describes the local requirements for managing and reporting incidents. Actions and responsibilities for all staff in the event of an incident are described in Appendix A and incidents that

    should always be reported (trigger list) are in Appendix B.

The Trust recognises that most events occur because of problems with systems rather than with

    individuals. The main aim of this policy is not to apportion blame to individuals but to ensure that

    there is organisational learning from adverse events, reduce risk in the future, and to provide support

    for any service users, staff and carers involved. The policy also ensures compliance with external

    risk management standards.

    The policy should be read in conjunction with the following policy available on the Trust Intranet:

    ? Risk Management Strategy (2008)

    ? Serious Untoward Incident Policy

2. Purpose

    This policy covers all adverse events no matter whom or what may be involved or how serious or minor the incident.

    This policy applies to everyone employed by the Trust and anyone working on or visiting Trust premises or places where the Trust provides healthcare in whatever capacity. It includes events involving service users, visitors, contractors, and those providing services under service level

    agreement, volunteers, students, people on work experience or secondment, agency and bank staff

    etc.

The purpose of reporting incidents is to identify actual or potential problems, so that these can be

    addressed. Its purpose is not to apportion blame.

    This policy describes how to manage all incidents within the Trust, including what to report, the

    reporting timescales and who needs to be advised of the incident. It also explains what actions must

    be taken, and who is responsible for these.

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    Incident Management Policy

3. Definitions of an Adverse Event, Near Miss or Hazard

    Please contact the Patient Safety Manager if you require any advice on the following definitions:

    An adverse event or near miss is any incident or circumstance arising in the course of providing or supporting the provision of health care services which could have or did lead to unintended or

    unexpected harm, loss or damage to a patient, member of staff or visitor, the Trust and its property

    or the environment.

Examples of incidents include:

    Delay in diagnosis, wrong diagnosis or incorrect assessment in relation to cytology screening services

    Administration of wrong drug or incorrect quantity of right drug

    Health records not available for a consultation

    Slips, trips and falls

    Incidents relating to Information Governance

    Patient ward transfers (if greater than 3)

    Health care associated infection

    Patient committing or attempting to commit suicide

    Homicide or assault involving a patient

    Fire

    Work related illness for staff

    Violence/aggression to staff

    Accidents involving any of the people covered by the policy

    Breach of patient confidentiality

    Where an event results in actual harm, loss or damage it is called an incident or adverse incident.

    Where an event did not result in actual harm, loss or damage it is called a near miss.

Near misses are as important to record and investigate as those incidents where actual harm was

    sustained. Near misses can highlight potential problems and allow the Trust to remedy matters

    before any harm results.

Incident The term incident” is used in the Trust to define any unexpected

    happening that gives rise to concern, whether it is related to patient care

    (clinical) or other issues (non-clinical) or to staff incidents Adverse incident The National Patient Safety Agency defines an adverse incident as an

    event or circumstance arising during NHS care that could have or did lead

    to unintended or unexpected harm, loss or damage Serious Untoward A serious untoward incident (SUI) is a grossly exceptional incident Incident involving the Trust and its staff, patients or visitors and has the potential

     to be of serious public concern. Incidents of this sort are infrequent but

     they can attract high levels of public or media interest.

    Accident Unexpected event, unintentional act or event that results in injury or ill-

    health

    Near miss Any incident which does not result in injury, ill-health, property loss or

    damage but has the potential to do so.

    MHRA-reportable incident The Medical and Healthcare Products Regulatory Agency requires all

    adverse incidents involving medical devices to be reported, even if user

    error (rather than a device problem) is suspected. In addition the MHRA

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    has a Yellow Card Scheme for spontaneous reporting of adverse drug

    reactions. This is a voluntary scheme and nurses, midwives, doctors,

    dentists, pharmacists and coroners are encouraged to use it. Full details

    are on the MHRA website www.mhra.gov.uk. See Appendix C for a full list

    of external reportable agencies.

    RIDDOR incident An incident reportable under the Reporting of Injuries, Diseases and

    Dangerous Occurrences Regulations 1995. Reporting accidents and ill-

    health at work is a legal requirement. See Appendix D. Hazard Property of a substance, article or situation which has the potential to

    damage people, equipment, materials or the environment Risk The likelihood that a hazard will cause damage to people, equipment,

    materials or the environment

    Security incident Includes thefts, suspicious behaviour, malicious and deliberate damage to

    property

    Violent incident Any incident where someone on Trust property (staff, patient, visitor or

    contractor) is verbally or physically abused, threatened or assaulted.

    Where a physical assault occurs the Security Management Service

    Physical Assault Reporting System form (PARS) must be completed to

    ensure the system is followed. The form is available on the Intranet in the

    Security section.

    Staff Anyone employed by the Trust in any capacity, whether clinical or non-

    clinical, and including consultants, clinicians, locums, contract and Bank

    staff.

    Manager Anyone with managerial responsibility for staff or tasks, whether clinical or

    non-clinical.

    Honorary staff Anyone with an honorary contract

    Trigger Events These are a defined set of adverse clinical events, which is produced by the

    Governance team, that requires automatic reporting. The trigger events

    would be, in most instances, likely to cover all the above categories of the

    adverse events (refer to Appendix B)

4. Audience

    This policy applies to all staff at South Warwickshire General Hospitals NHS Trust, in all healthcare settings and working environments.

    This policy should be read in conjunction with the Risk Management Strategy, Whistle Blowing Policy, Being Open Policy and Health and Safety Polices and Procedures.

    Those staff investigating claims, incidents or complaints must use the procedure, „Procedure

    for Investigating Incidents, Complaints and Claims‟ which will be available on the Trust Intranet.

5. Responsibilities / Duties

    All staff have a duty to report any adverse events using the standard incident reporting form. It is the responsibility of all line managers to ensure that their staff are aware of and adhere to

    these procedures and reporting mechanisms.

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    Incident Management Policy Chief Executive

    The Chief Executive has overall responsibility for Patient Safety. The Medical Director and Director of Nursing are the Executives with delegated responsibility for ensuring the

    implementation of this policy.

    Trust Board

    The Trust Board and Non-Executive Directors have collective responsibility for the implementation of this policy.

Governance Committee

    ? Consider incidents as part of the patient safety report

    ? Seek assurance that actions are taken, followed up and monitored in relation to incidents

    ? Report by exception to the Trust Board regarding incident management

    ? Receiving a monthly report regarding Serious Untoward Incidents (see Serious Untoward

    Incident Policy)

    Risk Management Board, Health and Safety Committee and sub groups

    ? Deciding which risk matters related to incidents are to be included on the Risk Register, and

    how they are to be prioritised and treated

    ? Considering evidence for risks that have been treated, and deciding when items should be

    reduced in priority on the register or removed

Patient Safety Manager

    ? Reviewing incidents reported not related to Health and Safety

    ? To review the electronic database in which incidents are recorded

    ? Ensuring that appropriate action is taken in relation to incidents, and monitoring the progress

    of action plans

    ? Producing statistics and narrative and analysing trends relating to incidents as part of the

    reporting process to Clinical Governance Committee, Divisional sub groups,

    Finance/Performance Committees, and specific operational areas of the Trust as agreed with

    them

    ? Reporting Serious Untoward Incidents (SUI) to the Strategic Health Authority and the PCT

    ? Report all patient safety incidents to the National Patient Safety Agency on a regular basis

    via the National Reporting and Learning System (NRLS)

    ? Training managers and staff with regard to incident management

    ? Monitoring compliance and reporting of RIDDOR incidents to the Health and Safety

    Executive under the Reporting of Injuries Diseases and Dangerous Occurrences Regulations

    1995

Health and Safety Advisor

    ? Reviewing incidents relating to health and safety

    ? Ensuring that appropriate action is taken in relation to incidents, and monitoring the progress

    of action plans

    ? Ensuring that any reportable incidents involving equipment are notified to the Medicines and

    Healthcare products Regulatory Agency (MHRA)

    ? Reporting physical assaults to the Security Management Service

    ? Training managers and staff with regard to incident management

Local Security Management Specialist (LSMS)

    Where a physical assault occurs the LSMS must be notified (dial extension 4706) and the Security Management Service Physical Assault Reporting System form (PARS) must be completed to ensure the system is followed. The form is available on the Intranet in the Security section. A Trust Incident Draft Version 1, April 2008 Page 6 of 20 Printed on 26/06/10

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    Incident Management Policy

    form also needs to be completed.

    Trust Managers

    ? Ensuring that all risk management issues are appropriately addressed within their area in line

    with the Risk Management Strategy, Health and Safety Policies and with this policy ? Managing incidents in and out of hours in line with the Incident Management Process ? Reporting to the Police any crime they become aware of that has occurred on Trust property,

    and following the Incident Management Process as described in Appendix E. The crime

    number allocated by the Police must be recorded on the incident report form ? Recording on the incident report form any immediate actions taken to reduce risk, and any

    further actions planned at this stage, and monitoring completion of these actions. Where no

    action is considered necessary this must be stated clearly on the form and signed by the

    manager

    ? Ensuring that staff in their control are familiar with this policy and implement it correctly. ? Ensuring that there is an Incident Report Book available at all appropriate points within their

    area of control, and that all staff know where it is situate.

    ? Ensuring that staff are allowed time to complete incident report forms within the specified

    timescales

    ? Advising the Patient Safety Manager or Health & Safety Advisor verbally or by e-mail

    immediately a RIDDOR reportable incident has occurred or is identified ? Providing support to staff involved in an incident, and directing staff to other sources of help

    (e.g. Clinical Director, Occupational Health, Clinical Psychology Service) ? Ensuring that they and their staff attend training as described in this document and as

    otherwise required

    Trust Staff

    ? Reporting incidents in line with this policy

    ? Implementing the Incident Management Process as described in Appendix E if they either

    witness or are involved in an incident or near miss

    ? Providing information to enable the Trust to comply with the requirements of the Health and

    Safety Executive in relation to the Reporting of Injuries Diseases and Dangerous

    Occurrences Regulations 1995 (RIDDOR). Where an incident results in staff taking time off

    work, whether immediately or subsequently, the member of staff or their line manager must

    report this to the Patient Safety Manager or Health & Safety Advisor either on the incident

    form or via separate written communication (including e-mail) immediately it is known ? Reporting any piece of actual or suspected faulty equipment immediately. If the equipment

    either has contributed or could have contributed to an incident, the Incident Management

    Process must be followed

    ? Assisting in the investigation of an incident on request from management

    On-call Manager

    ? Advising the on-call director immediately of any Dark Amber or Red Incidents occurring out of

    hours

    On-call Executive Director

    ? Managing any Dark Amber or Red incidents that occur out of hours in line with the Incident

    Management Process, until responsibility can be handed over to another appropriate

    manager if relevant

    ? Ensuring that the Chief Executive is advised immediately of Red incidents out of hours, and

    kept updated as requested regarding the incident

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    Incident Management Policy 6. Procedural Requirements

    It is important to remember that risk management is everybody‟s responsibility; and all staff must

    engage in the local resolution process where necessary. This may include discussion with your line manager about the incident or near miss and /or participating in the incident investigating process. Mere completion of an Incident report does not discharge staff of the duty of care and their risk

    management responsibility. Some incidents are easy to identify, such as when a patient falls whilst in the care of the Trust, or someone breaks into a building and steals the Trust‟s property. Others

    are less easy to identify, but a useful guideline is to report anything that causes concern, even if it

    has not yet caused harm (near miss). Repeated occurrences of seemingly minor incidents can be

    an indicator of a significant problem that may not be immediately apparent. Risk management is

    about taking action to prevent untoward things happening, or where there is a known risk, developing processes to manage the risk down to an acceptable level. The reporting of near misses

    is a key part of this process. A list of situations that must always be reported is provided in Appendix B, but this is not exhaustive. Serious incidents must always be reported immediately. Incidents of any severity may be the subject of a claim in the future, and the information provided on

    the incident form will assist in supporting or refuting a claim. The incident form, therefore, is a legal

    document and it is important that each one is completed fully and clearly, documenting all known

    facts about the incident, and not opinion and a legible signature of the person completing the form. No action will be taken against any individual for reporting such an event, save in exceptional

    circumstances, for example malicious motives or knowing disregard of required practice or

    procedure.

    All adverse incidents, concerns or near misses which impacts on person, services, property, reputation or finance must be formally reported on the Trust incident report form. The report must be completed, either by the member of staff who was involved in or witnessed the event, or by the

    person to whom the event was reported to, by the end of the working shift.

    The incident report must be accurate, complete and factual. Do not give opinions, draw conclusions or make subjective statements.

    In many cases the reporting of an incident may need no further action other than for information only. If the incident warrants investigations the line manager will grade the incident and prioritise it for

    further local action.

    If the incident is sufficiently serious, the line manager should escalate and involve their senior manager for any further investigation and follow-up actions.

    If no further action is deemed necessary after the incident, the fully completed WHITE copy should be sent to the Governance Department within 24 hours.

    Once the incident investigations and follow up actions (if any) are completed, the fully completed

    PINK must be sent to the Governance Department.

    The BLUE copy must be kept locally in a secure location for historical record.

    In the event of the line manager being off duty or on leave, a deputy must be identified to assume the responsibility for incident management, investigations and follow-up actions. The Patient Safety Manager will review all incident forms on the day of receipt and contact appropriate staff for further follow-up action as required. Certain categories of incident are reportable to external agencies such as the Medicines and Healthcare Products Regulatory Agency (MHRA), Health and Safety Executive, Environmental Health Department, and Police (see Appendix C) All staff are responsible for keeping their line managers informed about incidents occurring in their areas.

    All staff must be aware of their specific responsibilities in relation to this policy as listed in Appendix Draft Version 1, April 2008 Page 8 of 20 Printed on 26/06/10

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    Incident Management Policy A.

    A list of reportable incidents is contained in Appendix B

    A list of adverse events which are reportable under the RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulation) are listed in Appendix D.

7. Monitoring Compliance and Effectiveness

    The monitoring of all reported incidents is an ongoing process which will be monitored through quarterly reports to the assuring committees. The information included in reports will

    be assessed for relevance and quality of information.

    A summary of incidents will be sent to all managers on a quarterly basis and they will

    provide feedback, following discussion with their staff, on any actions taken, lessons leant

    and changes in practice as a result of reported incidents. This will be monitored by the

    Patient Safety Manager.

8. Author(s)

    S A Shelton Patient Safety Manager

9. Contributors

    Pat Morris Head of Governance

    Emma Ratley Standards Co-ordinator

10. Equality Impact Assessment Tool

    Is an Equality Impact assessment required? NO Preliminary Stage 1 Equality Impact Assessment (must be completed if required*) What date was Stage 1 completed and published? Has a Full Assessment Stage 2 Equality Impact NO Assessment Tool been undertaken*?

    If yes, what was the date of assessment and publication of Stage 2 and action plan?

    * See guidance notes on intranet

11. References

    Safety First (DH 2006)

Seven Steps to Patient Safety (NPSA 2004)

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    APPENDIX A: ACTIONS AND RESPONSIBILITIES FOR ALL STAFF IN

    THE EVENT OF AN INCIDENT

    Staff involved 1. Report all incidents immediately to line manager

     2. Ensure that medical attention or treatment is obtained if required

    3. Take immediate preventative action (if required) to avoid a similar accident

     or incident

    4. In the event of an incident involving a patient, notify the patient (if not

     already aware) and / or relatives as appropriate as per Trust policy ‘Being

     Open

    5. Retain any equipment involved and tag with label. (NB the equipment

     must be left exactly as it was at the time of the incident and no

     adjustments or intervention must be made unless required for safety

     reasons)

    6. Retain any medication and packaging involved, along with the medicine

     chart

    7. Retain any other documentation relating to the incident

    8. In the case of an incident involving a patient, record details in the patient‟s

     notes, including remedial treatment and aftercare. Medical staff are also

     required to enter appropriate details.

    9. Complete an incident form immediately and forward to line manager by the

     end of the shift

    Line manager 1. Ensure that all sections of the incident form have been completed

    2. In the event of a Serious Untoward Incident please follow the SUI policy

     and procedure

    3. Grade all incidents according to severity of outcome and undertake

     an investigation if deemed appropriate. (see Procedure for

     Investigating Incidents, Complaints and Claims - )

    4. If a written report is appropriate, forward to the Patient Safety Manager as

     soon as possible but in any event within 20 working days of the incident

    5. Keep the senior managers fully informed

    6. Ensure that corrective actions/recommendations are implemented

    7. The line manager must report to the Patient Safety Manager all

     staff who are off sick for three days or more as a result of an incident

     (whether at the time of the incident or subsequently) as part of the

     RIDDOR regulations

    8. For those staff involved in stressful incidents, refer to Procedure for Supporting

     Staff involved in Traumatic or Stressful Incidents, Complaints and Claims

     (SWH 00011)

    Senior Managers In the event of a Serious Untoward Incidents please follow the SUI Policy

     and Procedure

    Patient Safety 1. Patient Safety Manager to oversee and support any internal investigation

    Manager of any serious incidents including SUIs

    2. Review all reported incidents

    3. Forward copies of incident form appropriately

    4. Request further investigation if appropriate.

    5. Ensure relevant agencies have been notified

    6. Ensure all stakeholders have been informed

    7. Provide statistical information to:

    Health & Safety Committee

    Clinical Governance Committee.

    Divisional Clinical Governance Meetings (SAOGG & MAOGG)

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