North Bristol
NHS Trust
Clinical Governance Directorate
INCIDENT REPORTING POLICY
CG01
Date of Issue: June 2005
Approved at Clinical Governance Committee: May 2005
Date of Review: May 2006
North Bristol NHS Trust
Incident Reporting Policy – CG 1
1. Definitions
1.1 The National Patient Safety Agency define the term ‘patient safety incident’ as any event or circumstance arising during NHS care that could have or did lead to unintended or unexpected harm, loss or damage. Those incidents that did lead to harm are referred to as adverse events. Those incidents that did not lead to harm, but could have, are referred to as near misses.
1.2 The Health and Safety Executive define an accident as any incident that resulted in injury, ill health, or material damage. An incident is any unplanned event, which has the potential for causing injury, ill health or material damage without actual injury, ill health or material damage occurring, (i.e. a near miss).
However for the purpose of this policy all of the above will be referred to as an incident, i.e. any adverse event to patients, staff, visitors, property etc.
2. Policy Statement
2.1 It is the policy of North Bristol NHS Trust to take all reasonable steps to minimise the risk of harm to patients in the course of their treatment and care, to staff in the course of their work and to any third parties who may on Trust premises i.e. visitors and contractors. The Trust is committed to providing high quality care to patients within a safe environment by appropriately qualified and competent staff.
2.2 Effective risk management and incident reporting requires an open and learning organisation, where untoward and unexpected incidents are quickly recognised and acted upon in a constructive way where blame is not automatically apportioned to individuals.
2.3 When an incident occurs it is important that a thorough investigation is undertaken and the outcomes analysed in order that lessons are learnt for the benefit of patients, staff and the Trust as an organisation.
2.4 Although the Trust supports an open and learning culture for managing incidents, there will be occasions when the Trust’s disciplinary procedures will need to be considered following an incident; examples are:
· Repeated error, or failure to follow Policies or Procedures, involving the same member of staff
· Deliberate failure to report a serious incident
· Failing to co-operate with an investigation into an incident
· Criminal actions
· Action so far removed from reasonable practice that any competent practitioner would have been able to predict an adverse outcome.
3. Principles of the Policy
3.1 All staff will be aware of what constitutes an incident and be familiar with the Trust’s reporting arrangements.
3.2 All incidents will be graded when the incident report form is completed (refer to para 6 and 11) and investigated and actioned appropriate to the grade.
3.3 All serious or catastrophic incidents (code red) will be reported immediately and ‘fast tracked’.
3.4 All serious or catastrophic incidents (code red) will have a root cause analysis (RCA) undertaken.
3.5 The Trust will comply with external reporting requirements
3.6 Reports of incidents will be available for directorates and specialist trust groups to review regularly and action as appropriate.
3.7 Lessons learnt from incidents will be shared trustwide to prevent similar incidents occurring.
4. Reporting to External Agencies
4.1 Dependent on the type and seriousness of incident the Trust may be required to notify one or more of the following external agencies. These agencies may need to be contacted for guidance and advice during the investigation process.
· Health and Safety Executive (HSE) under RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995). The statutory duty includes recording accidents and reporting certain classes of accident. See appendix 2 for further details
· Medicines and Healthcare products Regulatory Agency (MHRA). Previously MDA and MCA.
· National Patient Safety Agency (NPSA) – via the National Reporting Learning System (NRLS)
· National Confidential Enquiry into Peri Operative Deaths (NCEPOD)
· Confidential Enquiry into Maternal and Child Health (CEMACH) previously CEMDI and CESDI.
· Confidential Enquiry into Suicide and Self Harm (CEISS)
· Department of Health
· Serious Hazards of Transfusion (SHOT)
· Radiation Protection Agency
· Strategic Health Authority (SHA) – see Appendix 6 for further details
· NHS Litigation Authority
· NHS Estates (firecode & buildings & non-medical equipment defect & failure reporting)
· Professional Registration Bodies (NMC;GMC etc.)
· Police
· Coroner
· Home Office
· Counter Fraud and Security Management Service (CFSMS)
· The Centre of Communicable Disease Control (CCDC)
· Relevant social care organisations
5. Scope of the Policy
5.1 The policy applies to:
All staff who have either witnessed an incident, been directly involved in an incident, discovered that an incident has occurred or have been told that an incident occurred.
6. Grading of Incidents
6.1 To aid trend analysis of all incidents a grading process will be applied taking into account two factors:
· Frequency of the type of incident
· Severity or outcome of the actual incident
6.2 The actual outcome and likely frequency of the incident should be graded by the member of staff completing the incident (AIMS) report, using the following tables as a guide, in accordance with NPSA requirements. After the investigation the incident may be re-graded by the investigating member of staff.
Table 1. Frequency of the type of incident
Level / 1 / 2 / 3 / 4 / 5Descriptor / Rare
or / Unlikely
or / Possible
or / Likely
or / Almost certain
or
Likelihood / Frequency / Can’t believe that this will happen – not expected to occur for years / Expected to occur at least annually / Expected to occur at least monthly / Expected to occur at least weekly / Likely to occur on many occasions, at least daily
Table 2. Severity or outcome of the actual incident (the following table illustrates examples of severity)
Level / 1 / 2 / 3 / 4 / 5Descriptor / Insignificant / Minor / Moderate / Major / Catastrophic
Injury / Minor injury not requiring first aid / Minor injury or illness, first aid treatment needed / Short term harm, RIDDOR/MHRA reportable, requires medical treatment. / Major injuries, or long term incapacity / disability (loss of limb) / Death or major permanent incapacity
Patient Experience / Unsatisfactory patient experience not directly related to patient care / Unsatisfactory patient experience – readily resolvable / Mismanagement of patient care / Serious mismanagement of patient care / Totally unsatisfactory patient outcome or experience
Complaint / claim potential / Locally resolved complaint / Justified complaint peripheral to clinical care / Below excess claim. Justified complaint involving lack of appropriate care / Claim above excess level. Multiple justified complaints / Multiple claims or single major claim
Service / Business interruption / Loss / interruption >1 hour / Loss / interruption >8 hours / Loss / interruption >1 day / Loss / interruption >1 week / Permanent loss of service or facility
Human Resources / Org. development / Normally recruit and retain staffing to level of funded establishments with occasional shortfalls not affecting service provision, but increasing service cost / On-going difficulties in recruiting and retaining staff which reduces service quality or increases cost of service provision / Significant difficulties in recruiting and retaining staff which leads to late delivery of key objectives and some shortfalls in service delivery and service quality. Minor errors due to insufficient training / Major difficulties in recruitment and retention which leads to significant late delivery of key service objectives, or errors in service provision / Major staffing deficiencies leading to non delivery of key service objectives, and critical errors in service provision
Financial / Small loss >£1000 at Directorate level / Loss <£5,000 at Directorate level / Loss <£50,000 at Directorate level / Loss <£100,000 at Directorate level.
Major impact on Financial Service Targets / Loss <£200,000 at Directorate level. Major impact on Financial Service Targets
Inspection / Audit / Minor recommendations. Minor non-compliance with standards / Recommendations given. Non-compliance with standards / Reduced rating. Challenging recommendations. Non-compliance with core standards / Enforcement action. Low rating. Critical report. Multiple challenging recommendations. Major non-compliance with core standards / Prosecution. Zero rating. Severely critical report
Adverse Publicity / Reputation / Rumours / Local Media – short term / Local Media – long term / National Media <3 days / NHSE investigation. National Media >3 days. MP Concern (Questions in the House)
Targets / Objectives / Slight reduction in scope/quality. Insignificant cost increase. Interim & recoverable position / Partial failure to meet subsidiary Trust objectives. Minor reduction in quality / scope / Definite escalating risk of non recovery of situation. Definite reduction in scope or quality. / Sustained position and predicted failure to meet key Trust objectives. Does not meet subsidiary objectives / Complete failure to meet key Trust objectives
Major reduction in scope or quality
6.3 The appropriate score is assigned from the above tables and multiplied to give a grading to the incident e.g. 5 (almost certain) x 2 (minor) = 10 (Amber)
The higher the incident scores the greater the risk. Therefore it is important that all incidents are graded to facilitate the identification of risk. Grading also enables resources to be targeted in a prioritised manner when implementing risk reduction strategies identified during the investigation.
ConsequenceLikelihood / 1 Insignificant / 2 Minor / 3 Moderate / 4
Major / 5 Catastrophic
5 - Almost Certain / Amber 5 / Amber 10 / Red 15 / Red 20 / Red 25
4 – Likely / Amber 4 / Amber 8 / Red 12 / Red 16 / Red 20
3 – Possible / Green 3 / Amber 6 / Amber 9 / Red 12 / Red 15
2 – Unlikely / Green 2 / Green 4 / Amber 6 / Amber 8 / Red 10
1 – Rare / Green 1 / Green 2 / Amber 3 / Amber 4 / Red 5
7. Investigation of Code Red Incidents (Serious Incidents)
7.1 All incidents which are graded red on the grading matrix (scoring 12 or more, or the grading falls in the catastrophic column) require to be fast tracked (see section 11.6 of the policy). Examples of incidents that would be graded red (but not limited to) are:
· inappropriate surgery performed ( wrong side/wrong patient)
· unexpected death
· suicide and serious self harm
· homicide
· ‘rogue staff’
· serious care management issues e.g. wrong blood transfused
· serious breach of confidentiality
· serious medication error
· events that affect multiple patients i.e. ‘rogue staff’, infected worker, incorrect interpretation of specimens.
7.2 Examples of non-clinical incidents that would be grade red (but not limited to) are:-
· Serious damage to premises – resulting in patient/staff injury and/or disruption to service
· Evacuation of ward/s due to utilities failure e.g. power, medical gases
· Malicious activity e.g. tampering with equipment
· Security issues – abduction/abscondment
· Serious assault on staff/visitor
· Incident that results in a fatality or major injury to staff, visitors or contractors
· Dangerous Occurrence as defined in RIDDOR
7.3 Additionally, “near miss” incidents that have a likely potential to result in a catastrophic outcome in the event of a recurrence should be reported and investigated as a Code Red, to ensure that risks are minimised proactively.
7.4 All serious or catastrophic incidents (code red) require a root cause analysis (RCA) to be undertaken, and the report and action plan produced within one month of the incident. This will ensure that an in-depth investigation is undertaken, identifying how the incident occurred so that lessons can be learned and appropriate actions taken to prevent a similar incident happening again. As a result of the investigation it may be appropriate to re-grade the incident.
7.4 Guidance and support for local managers on conducting a root cause analysis can be obtained from:
· Appendix 3 – Guidance for Staff undertaking a RCA for a serious/code red incident
· NPSA - RCA toolkit – www.npsa.nhs.uk/rca
· HSE - Investigating accidents and incidents. A workbook for employers, unions, safety representatives and safety professionals.
· Directorate RCA link (each directorate has nominated one member of staff who has undertaken the NPSA 3 day RCA training course)
· Clinical Risk Dept. (extension SM 5587)/Health & Safety Services.(extension SM 3251)
8. Links with other Trust Policies
8.1 The policy should be read with reference to the following Trust policies, which should be referred to dependent on the particular circumstances of the incident. Note: Most policies are available on the Trust’s intranet. (See Appendix 8)
· Risk Management Strategy
· Health and Safety Policy
· Medical Equipment Policy
· Blood Transfusion Policy
· Marking the correct patient for the correct operation/procedure
· Raising concerns about Healthcare Services
· Protecting Health Care Workers and Patients against infection with Blood Borne Viruses
· Prevention and Management of Latex Allergy
· Disciplinary Procedure
· Capability Policy
· Complaints Policy
· Claims Policy
· Major Incident Plan
· Service Continuity Plan
· Media Policy and guidance
· Health Records Policy
.
9. Incident Reports
9.1 All incidents will be entered into the Trust’s database which will link with the Complaints, PALS and Claims modules.
9.2 Summary reports will be provided regularly to the directorates and on request.
9.3 Reports will be provided to individual wards/departments on request.
9.4 Reports will be provided to specialist Trust groups to review and action as appropriate.
9.5 An annual report of incidents will be produced by the Clinical Risk Managers (clinical incidents) and Head of Health and Safety Services (non-clinical incidents) including trend analysis.
9.6 Incidents will be reported to external agencies (see section 4) as required. A detailed report will be supplied by the appropriate department e.g. RIDDOR incidents – Health & Safety Services, NPSA, NRLS – Clinical Risk Department