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North Bristol NHS Trust

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									                                      North Bristol NHS Trust

                                  Clinical Governance Directorate

                                 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 and 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 and to staff in the course of
           their work. 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 a “no blame” 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 involving the same member of staff
                  Deliberate failure to report an 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 (code red) incidents will be reported immediately and „fast tracked‟.

     3.4   All code red incidents will have a root cause analysis (RCA) undertaken.

     3.5   Reports of incidents will be available for directorates and specialist trust groups to review
           regularly and action as appropriate.


                                                                                                          1
           3.6     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.

                        Medicines and Healthcare products Regulatory Agency (MHRA). Previously MDA
                         and MCA.
                        National Patient Safety Agency (NPSA) Reporting procedures yet to be finalised.
                        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)
                        D.o.H
                        Serious Hazards of Transfusion (SHOT)
                        Strategic Health Authority (SHA)
                        NHS Litigation Authority
                        NHS Estates ( firecode & buildings & non-medical equipment defect & failure
                         reporting)
                        Professional Registration Bodies ( NMC;GMC etc.)
                        Police
                        Coroner
                        Home Office
                        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 incident should be graded by the member of staff reporting the incident using the
                   following tables as a guide. After the investigation the incident may be re-graded by the
                   investigating member of staff.

Table 1. Frequency of the type of incident
 Level      Descriptor                               Description
 5          Almost certain                           Likely to re-occur on many occasions, a persistent issue

 4          Likely                                   Will probably re-occur but is not a persistent issue

 3          Possible                                 May re-occur occasionally

 2          Unlikely                                 Do not expect it to happen again but it is possible

 1          Rare                                     Can‟t believe that this will happen again.

                                                                                                               2
    Table 2. Severity or outcome of the actual incident (the following table illustrates examples of
    severity)

Level   Actual or Potential Impact        Actual or Potential       Number of Persons      The potential for
        on Individual(s)                  impact on                 affected at one time   complaint/
                                          Organisation                                     litigation
5       DEATH                             International adverse     Many(>50)              Litigation expected/
        Unexpected death of a             publicity                 cervical screening     certain > £1 million
        patient whilst under the direct   NHSE investigation        disaster evacuations
        care of a health care             Extended service          Vaccination error
        professional.                     closure                   etc.
        death resulting from an
        accident at work
        Known /suspected case of
        health care associated
        infection which may result in
        death.
4       PERMANENT INJURY                  National adverse          Moderate number        Litigation expected/
        procedures involving the          publicity/major loss of   16-50 (e.g. loss of    certain £500K – £1
        wrong patient or body part(s)     confidence in             specimens              million
        haemolytic transfusion            organisation.             vaccination
        reaction                          Temporary service         problems)
        retained instruments/ other       closure                   Increased length of
        material after surgery            RIDDOR reportable         stay/care >15days
        requiring re-operation            Long term sickness >4
        An accident resulting in loss     wks
        of limb or sight etc.
        known/suspected case of
        healthcare associated
        infection which may result in
        major permanent harm e.g.
        hepatitis C
        patient receiving a radiation
        dose much greater or less
        than intended.
        infant abduction or discharge
        to the wrong family
3       SEMI PERMANENT                    Local adverse             Small numbers          Litigation possible but
        INJURY/DAMAGE                     publicity/moderate loss   e.g. 3 – 10            not certain
        i.e. injury that takes up to 1    of confidence in the      Increased length of    £50K - £500K
        year to resolve                   organisation.             stay/care 8 - 15days   High potential for
        e.g.                              RIDDOR reportable                                complaint
        Known or suspected health         MDA reportable
        care associated infection,        Short term sickness <4
        which may result in semi-         wks
        permanent harm.
        Accident resulting in
        fractured limb
2       SHORT TERM                        Minimal risk to           One                    Complaint possible
        INJURY/DAMAGE                     organisation              Increased length of    Litigation unlikely -
        i.e. injury that has been         Staff sickness <3 days    stay/care 1 – 7 days   <£50K
        resolved within one month
        e.g.
        Known or suspected health
        care associated infection
        which may result in non-
        permanent harm.
1       NO INJURY OR ADVERSE              No risk at all to         One – none             Unlikely to cause
        OUTCOME                           organisation                                     complaint
                                                                                           Litigation risk remote




                                                                                                           3
      6.3      The appropriate score is assigned from the above tables and multiplied to give a grading
               to the incident. The higher the incident scores the greater the risk. Therefore it is
               important that all incidents are graded to facilitate the identification of risk.

      6.4      Using the matrix below the scores will be assigned a colour rating.

               e.g. 5 (almost certain) x 2 (minor) = Amber

                                                           Consequence
                          1                 2              3                     4               5
                          Insignificant     Minor          Moderate               Major          Catastrophic
Likelihood
5 - Almost Certain        Amber 5           Amber 10       Red       15          Red      20     Red       25
4 – Likely                Yellow 4          Amber 8        Red       12          Red      16     Red       20
3 – Possible              Green 3           Yellow 6       Amber 9               Red      12     Red       15
2 – Unlikely              Green 2           Green    4     Yellow 6              Amber 8         Amber 10
1 – Rare                  Green 1           Green 2        Yellow 3              Amber 4         Amber     5


7.    Investigation of Code Red Incidents (Serious Incidents)

      7.1      All incidents involving patients which are graded red on the grading matrix (12 or more)
               require fast track reporting (see section 11.6 of the policy) in line with the NPSA reporting
               requirements. 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‟
                    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:-

                  Collapsed ceiling
                  Examination of ward due to power failure
                  Rogue staff
                  Security issues – abduction/abscondment
                  Staff assault

      7.3      All code red incidents require a root cause analysis (RCA) to be undertaken within the
               NPSA deadlines for the benefit of fully understanding what and why 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.

               Full guidance and support for local managers on conducting a root cause analysis will be
               provided by the Trust Risk Managers.

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.

                    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
                                                                                                                4
                    Protecting Health Care Workers and Patients against infection with Blood Borne
                     Viruses
                    Prevention and Management of Latex Allergy
                    Disciplinary Procedure
                    Complaints Policy
                    Claims Policy
                    Major Incident Plan
                    Service Continuity Plan

            Where to find them is detailed on Appendix 3.


9.    Incident Reports

      9.1   All incidents will be entered into the Trust‟s data-base which will link with the complaints,
            PALS and claims data-base.

      9.2   Summary Reports will be provided regularly to the directorates and on request.

      9.3   Reports will be provided to specialist Trust groups to review and action as appropriate.

      9.4   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.

10.    Learning Lessons

      10.1 The Trust will ensure lessons are learnt from incidents, whether they are individual
           events, aggregated reviews or from the wider experiences of the NHS.

      10.2 Directorates will be expected to develop action plans as appropriate to ensure similar
           incidents do not occur.

      10.3 RCA Reports will be received by the relevant risk committee and progress against action
           plan will be reviewed 6 monthly as appropriate.

      10.4 Themes emerging from the analysis of incident data will be shared with the staff by
           newsletter, feeding into training programmes and clinical audit programmes.

      10.5 National Confidential Enquiries will be reviewed by Clinical Effectiveness Committee for
           any correlation with incident trends identified in the trust.

11.   Procedure for reporting incidents

      11.1 All incidents in the Trust will be reported using the Accident and Incident Management
           System (AIMS) form. The exceptions to this principle are pharmacy and pathology where
           they have their own systems of recording their clinical interventions. However a 6 monthly
           summary report will be provided for review at the Clinical Risk Committee.

      11.2 Instructions for the completion of the form are contained on the inside of the front cover of
           the AIMS pad.

      11.3 The staff member completing the AIMS form must record fact and not opinion. A
           contemporaneous record should be kept and security stored.

      11.4 Statements made in the course of the investigation will be disclosable in the event of a
           claim being made against the Trust and may be disclosable to the Coroner.

      11.5 The AIMS report or copies of the report must not be filed in the patient‟s health record.

      11.6 Green to Amber Graded Incidents

            11.6.1      The member of staff reporting the incident is responsible for;


                                                                                                            5
          Ensuring the immediate healthcare needs of the patient/s involved are
           maintained.

          Informing their senior clinician/line manager immediately.

          Grading the incident and completing an AIMS form within 12 hours of the
           incident occurring. The first 3 copies of the 4 self-copying form are removed
           from the pad. The top notification copy is posted or faxed to either the
           Clinical Risk Management Department or the Health & Safety Department as
           appropriate within 24 hours. The Managers Report is sent to the senior
           clinician/line manager as determined by the directorate‟s local arrangements.
           The Originators copy, if a staff member is involved, is kept by themselves for
           their own record. The 4th copy is left in the pad.

11.6.2   The senior clinician/line manager will review the initial grade of the incident and
         fast track the process if it warrants a code red (see section 6.4) or re-grade if
         appropriate. If fast-tracking is not necessary, then the senior clinician/line
         manager is responsible for ensuring the following action is taken.

         Out of hours this role will be undertaken by the Clinical Site Manager

          Informing the relevant medical staff; a judgement must be made as to
           whether immediate medical examination is required

          Ensuring that defective equipment and consumables involved in the incident
           are taken out of commission and retained safely and undisturbed for later
           examination

          Ensuring Health and Safety Services are informed of any incident reportable
           to HSE under RIDDOR

          Ensuring all relevant departments are alerted, e.g. Clinical Engineering,
           Pharmacy, Works Engineers, CSMT etc.

          Investigating the events surrounding the incident and ensuring actions are
           undertaken as appropriate.

          Completing the Managers Report within 3 weeks and forwarding it to the
           general manager/head of clinical/ nursing director as appropriate.

          Implementing and monitoring any immediate changes in working practices
           designed to prevent a reoccurrence of the incident.


11.6.3   The General Manager is responsible for;

          Reviewing all Managers reports and re-grading if appropriate. Completed
           managers‟ reports should be sent to either Clinical Risk Management or
           Health & Safety Services within 3 weeks of the incident occurring.

          Ensuring the incidents summary reports are reviewed regularly and actioned
           as appropriate at the Directorates‟ Risk Group (or similar forum)

          Ensuring that changes in working practices have been implemented and
           monitored, a summary report will be required as evidence for the directorate
           clinical governance performance reviews

          Ensuring that risks identified by incidents are assessed and controls
           implemented to reduce the risk. If appropriate risks are to be included on
           directorates‟ risk register.

11.6.4   Clinical Risk Managers are responsible for;

          Maintaining the Trust‟s data-base of clinical incidents
                                                                                           6
                        Providing regular reports for the directorates and trustwide committees e.g.
                         medicines governance, medical records

                        Providing reports to the Clinical Risk Committee, Clinical Governance
                         Committee and Executive Management Team as required.

                        Interrogating incident data-base , identifying trends across the Trust as a
                         whole


             11.6.5    The Head of Health and Safety Services is responsible for;

                        Maintaining the data base for health and safety incidents

                        Reviewing health and safety reports, identifying trends across the Trust as a
                         whole

                        Providing reports to the Health and Safety Committee, Non Clinical Risk and
                         Controls Assurance Committee and Executive Management Team as
                         required

                        Notifying the HSE of any incidents reportable under RIDDOR. Liasing with
                         HSE as appropriate.

11.7     Red Graded Incidents

        11.7.1 If an incident is graded as red then the following actions will be taken
               immediately. Due to the serious nature of the incident the senior
               clinician/manager should notify the Clinical Director/General Manager/Head of
               Nursing or if out of normal hours the senior clinician/manager on call.

        11.7.2 A decision will be taken whether to notify the Medical Director, Nursing Director
               immediately. In addition the Medical/Nursing Director will decide whether to
               notify the Chief Executive. Consideration must also be given to whether any of
               the external agencies listed in section 4 should also be notified of the incident.

        11.7.2 The senior clinician/manager or clinical site manager is responsible for;

Office Hours                                          Out of Hours
Responsible: the senior clinician/manager             Responsible: Clinical Site Manager
Informing the patient of the facts (not opinion) of   Informing the patient of the facts (not opinion) of
the incident. Patient must be informed before the     the incident. Patient must be informed before the
media. Relatives and staff involved should be         media. Relatives and staff involved should be
informed as appropriate.                              informed as appropriate.
Informing the head of nursing/department,             Informing the head of nursing/department,
general manager/clinical director immediately         general manager/clinical director immediately or
                                                      by the end of the shift
Informing the patient‟s medical staff immediately     Informing the patient‟s medical staff immediately
                                                      or ensuring information is passed on at the end of
                                                      the shift

Informing the clinical risk manager/health & safety   Ensuring the clinical risk manager/health &
and Trust press office immediately                    safety/Trust press office are notified by leaving a
                                                      message on ansaphone
Ensuring that staff involved receive support          Ensuring that staff involved receive support
Ensuring statements are taken from staff who          Ensuring statements are taken from staff who
were involved with the incident (they should be       were involved with the incident (they should be
legible, signed, dated and timed)                     legible, signed, dated and timed)
Ensuring that any equipment/medication involved       Ensuring that any equipment/medication involved
in the incident is taken out of commission and        in the incident is taken out of commission and
securely stored for later inspection                  securely stored for later inspection


                                                                                                        7
11.7.4 The Clinical Director/General Manager or the Medical Director/Nursing Director if
       directly notified are responsible for;

               Informing all other appropriate Executive Directors. Other Clinical
                Directors/Operations Directors might need to be informed if the incident
                extends to service from other directorates.

               Undertaking a preliminary investigation

               Ensuring that the patient(s)/staff/visitor(s) and /or their relatives have been
                informed if the individual has been harmed

               Collecting all relevant records/documents and reports and if necessary take
                photocopies of patient health record.

               Ensuring that the reporting procedure to any external agency (see section 4)
                if appropriate, has been completed

               Drafting a preliminary report for the Chief Executive and Executive
                Management Team

               Ensuring that urgent remedial actions have been take to prevent a
                reoccurrence of the incident

               Ensuring staff have the opportunity to have a debrief. (See Appendix 1)

               Ensuring, as appropriate, those patients, relatives, staff and the press office
                are kept informed of developments.

               Ensuring that all other departments in the Trust are informed as appropriate
                of the incident and management of the investigation. Legal Advisor, Press
                Officer, Avon Occupational Health Partnership and Health and Safety
                Services. In addition the following may need to be notified: patient‟s GP,
                Police, NPSA and Strategic Health Authority.

    11.7.5    The Executive Director in liaison with the Clinical Director/General Manager and
              Directorate Head of Nursing is responsible for;

               Ensuring the Chief Executive is informed of the incident and regularly
                updated.

               Receiving the preliminary report from the responsible Clinical Director/
                General Manager

               Agreeing a press statement for the Chief Executive

               Agreeing with the Chief Executive the form of internal/external
                investigation/enquiry that will be convened

               Agreeing the team to undertake a root cause analysis and ensure NPSA
                time-scales are met.

               Agreeing with the Chief Executive the need for an emergency „hotline‟ to be
                established to deal with multiple enquiries.

    11.7.5    The General Manager, Clinical Governance is responsible for;

               Establishing and managing the emergency „hotline‟. (appendix 2)
               Informing the chairs of the Clinical/Non Clinical Risk Committees that an
                incident has occurred and an investigation convened.
               Liasing as appropriate with the following; Strategic Health Authority, CHC.



                                                                                                  8
            11.7.6    The Press Office is responsible for;

                       Checking with the ward/department that those directly affected by the event
                        are informed of incident before the media.
                       Co-ordinating the Trust‟s response to the media
                       Preparing media briefings for patient, relatives, staff and public.
                       Documenting all information given to the above.
                       Preparing for VIP visits

            11.7.7    The Clinical Director/General Manager is responsible for;

                       Implementing recommendations arising from the enquiry
                       Monitoring the effect of the implementations
                       Ensuring that staff receive any training/skills update

12.   Review

      This policy will be reviewed every year from date of ratification.


Revised                                                    May 2003

Agreed by Clinical Risk Sub-Committee                      June 2003

Ratified by Clinical Governance Committee                  June 2003

Policy review                                              June 2004


Previous edition agreed by Clinical Risk Committee April 2001 and ratified by Clinical Governance
Committee June 2001



Reference should be made to the following Trust policies/procedures:

CG02 Risk Management Policy (revised February 2003)                                                 PDF

HS01 Trust Health & Safety Policy                                                       Nov      PDF
                                                                                        2000
HS02 Protecting Health Care Workers and Patients Against Infection with Blood           Jan      PDF
     Borne Viruses                                                                      2001
HS03 Prevention and Management of Latex Allergy                                         Dec      PDF
                                                                                        2001


For further information:

Health and Safety Executive                                        www.hse.gov.uk

National Patient Agency                                            www.npsa.org.uk

Medicines & Healthcare Products Regulatory Agency                  www.medical-devices.gov.uk

NHS Litigation Authority                                           www.nhsla.com

Confidential Enquiry into Maternal and Child Health                www.cemach.org.uk

National Confidential Enquiry into Peri Operative Deaths           http://www.ncepod.org.uk/index.htm

Serious Hazards of Transfusion (SHOT)                              http://www.shot.demon.co.uk

K:\Gordon & Jane\Clin Gov\Incident policy May 2003.doc

                                                                                                        9
                                                                                                           Appendix 1
                                          NORTH BRISTOL NHS TRUST

                                     Clinical Governance Directorate

                              Critical Incident Debriefing (CID) Protocol

1.   Introduction

     1.1      The purpose of this protocol is to provide a framework for staff who are required to undertake a debriefing
              session following a serious critical incident.

     1.2      Debriefing staff who have been involved in a serious critical incident should be an integral part of any
              follow up action/s.

     1.3      As in line with the Trust‟s Risk Management Strategy, this protocol should follow the principle of “no
              blame” when staff are being debriefed.

2.   What is a debrief?
     2.1      It has been described as „ a group meeting to review the impressions and reactions of survivors,
              bereaved or helpers experienced during or following critical incidents, accidents or disasters.‟ However it
              should be noted that individuals can also be successfully debriefed using the same principles.

     2.2      Debriefing also allows the Trust to evaluate its response and identify lessons to be learnt at
              operational, tactical, and strategic level.

3.   Why should we debrief?
     3.1      Debriefing can help people cope with and recover from the incident after effects. It helps participants
              understand that they are not alone in their reactions to distressing events and provides them with an
              opportunity to discuss thoughts and feelings in a controlled, safe environment.

4.   What incidents will require a debrief?
     4.1      CID was originally developed for the benefit of emergency services and military personnel. However, the
              principles can be transferred to a healthcare setting and therefore incidents which would require
              debriefing would include, though not limited to, the following:

                     Instigation of the Major Incident Plan
                      Instigation of the Service Continuity Plan e.g. power failure, fire
                      Instigation of “Hot Line”
                      Baby/Child Abduction
                     Death/serious injury to patient/s following a serious healthcare service failure/near miss.
                      Staff violence
                      Sudden unexpected death

5.   When should the debrief be undertaken?
     5.1      As soon after the incident as possible, ideally within 24 to 72 hours post incident.




                                                                                                                     10
6.   Who should determine whether debriefing is required?

     6.1       The on-call General Manager will have the responsibility for determining the extent and the detail of the
               initial debriefing and reporting back post debriefing to the appropriate Executive Director/s who will
               determine whether a general debrief should be undertaken.

     6.2       In the event of a maternal death or baby abduction, the Supervisor of Midwives will determine the extent
               and detail of the initial debriefing.

7.   Who should undertake the debrief?

     7.1       The debriefing session should be undertaken by staff who have the required skills to undertake
               the process e.g. group dynamics, counselling. Refer to the Trust‟s Major Incident Plan where
               key Trust staff have been identified.

8.   There should be 2 types of debriefing

     8.1       Initial Debrief

               This is where:

                The end of the incident is formally acknowledged.

                Staff are provided with information to complete the picture of the incident and its response.

                Staff are allowed to share their experiences.

                All staff involved are registered so that any follow up arrangements can be comprehensive.

                A „signposting‟ service is provided with regard to any planned arrangements and lessons
                 learnt.

                Staff are advised that arrangements are being made to hold a series of meetings to
                 disseminate the general information to as many staff as possible. If possible date, time and
                 venue is given.

     8.2 General Debrief

                As many staff involved in the incident as possible to attend.

                Dates, times and venues to be widely disseminated.

                To take place within 48 hours.

                Contact numbers of support services to be provided (internal & external)

                Make notes of concerns/issues raised at meeting, ensure that they are followed up.


9.   Where should it be done?

     9.1       In a room large enough to hold the expected amount of staff, away from interruptions. Flip charts, pens,
               beverages to be available, with contact numbers for staff support services.




                                                                                                                     11
10.   What support should be provided for staff after the incident?

       A letter of acknowledgement should be sent to all members of staff who were involved in any way with the incident.
                   It should be drafted and signed by the Chief Executive within 72 hours of the end of the incident being
                   declared. However, in some instances, it may be more appropriate for the letter to be signed by the
                   Clinical Director or Head of Nursing. This very much depends upon the nature of the incident.

       Staff should be granted leave of absence, if necessary at the discretion of their line managers.

                If possible, and if necessary, re-assign staff to new duties/areas eg; if staff workplace is temporarily out of
                 action.

                Provide staff with support services and time off to attend appointments etc.

11.   How should actions be followed up?

                A senior member of trust staff will be nominated by the Executive Management team and will be
                 responsible for following up actions post incident

       Follow up will depend on circumstances but might include revision of plans and procedures,
                strengthening liaison with other agencies, devising small exercises to test alternative
                approaches.

       Where there has been a considerable amount of media attention a senior media representative will be
                invited to meet with key senior staff some weeks after the incident to review the events and how
                it could be better managed in the future.

       Lessons learnt and actions implemented to prevent a similar occurrence will be reported back to staff
               within 1 month via special meetings, trust intranet & insite magazine.




JW– Risk Manager
February 2003




                                                                                                                            12
                                                    North Bristol NHS Trust

                                                 Debriefing Checklist

                        (For Managers required to initiate a debrief following a critical incident)

                                                                                             TICK

1.    Time – should be within 24hrs of incident                                          

2. Room – large enough to hold expected staff                                            

3. Staff facilitating session – staff member with necessary skills                       

4. Notify all staff involved:

        – contact individuals                                                            
        - notices in communal facilities eg; staff rooms/toilets                         

5. Equipment :

        – flip charts                                                                    
        - pens                                                                           

6.      Beverages – order tea/coffee to be available.                                    

7. Attendance Sheet:

        -    staff to sign in                                                            
        -    ensure staff contact numbers are included                                   

8.      Note taking – organise someone not involved in the events to take                
        notes of debrief.

9.      Contact numbers – of counselling/support services to be available                

10.     Follow up - advise staff what will happen next eg; required to
        make formal statements, type of inquiry – informal, police, HSE, Fire            

11.     Feedback – report back to on-call Director                                       




February 2003




                                                                                                      13
                               North Bristol NHS Trust                                Appendix 2
                                Clinical Governance Directorate

                                Protocol for Emergency Helpline

1.   Introduction

     1.1        The following protocol has been developed from the Directorate‟s experiences in
                managing the emergency help-line for organ retention following the publication of the
                Alder hay Report in January 2001.


2.   Establishment of the Helpline

     2.1        The decision of the establishment of the helpline will be made by the Chief Executive or
                Deputy in his/her absence.

     2.2        He/She will decide whether the emergency warrants the Clinical Governance Directorate
                to staff the helpline. If not they may be advised to remain on stand-by to be called at a
                later date.

3.   Location

     3.1        The control room for emergency helpline will be located in the Ops Meeting Room, 2nd
                Floor, THQ.

     3.2        The calls to the help line may be transferred to Patient Affairs Office, Southmead if the
                number of calls reduces to a manageable level. This will be at the discretion of the
                Operations Director and the Chaplaincy Service.

4.   Equipment

     4.1        The following equipment is available for use/or to be available:

                   3 phone lines (2 internal extensions, 1 DDL)
                   1 Fax machine/answerphone to be collected from the Patient Affairs Office)
                   1 laptop computer with access to e-mail.
                   3 headphones for the telephones.

5.   Team

     5.1        The Operations Director for Clinical Governance will be responsible for pulling together a
                team to staff the helpline from the following staff:

                   Patient Representative Service
                   Complaints Service
                   Risk Management Service
                   Chaplaincy Service
                   Practice Development Team

6.   Preparation

     6.1        The Operations Director will:

                 Contact staff to ask availability for staffing the help-line and organise the roster.
                 Brief the team of the emergency.
                 With the team devise the script for the opening instructions and line to take regarding
                       queries.

                                                                                                        14
              Nominate a team leader
              Set up the control room with the team leader
              Ask the reception staff in THQ, to cancel meetings booked in Ops Meeting Room.
              Order beverages
              Devise caller log sheet
              Liaise with Press Office, Operations Director, Corporate Affairs and others as
                    appropriate.
              Contact internal or external agencies for staff support if appropriate

     6.2     The Team Leader will:

                Alert switchboard of the helpline
                Test helpline numbers
                Ensure supplies of log sheets
                Establish log system
                Brief team on the use of the equipment e.g., answerphone, transferring calls etc.

7.   During the Emergency

     7.1     The Team Leader will:

                     Be available, to sort out queries/problems.
                     Be available to answer queries from interested parties e.g., press office.
                     Keep an up to date log of number of callers and other relevant details.
                     Liaise with Operations Director daily or more often as appropriate.
                     Monitor how call staff are coping with the emergency and arrange for support if
                      needed.

     7.2     The Operations Director will:

                     Receive a daily update form the team leader and brief Chief Executive as
                      appropriate.
                     Be available to report at the Senior Crisis meetings.
                     Organise the setting up of the database to log calls and follow up actions.
                     Provide additional support for team to fulfil normal workload if and when required.
                     Notify switchboard, press office operations Director, Corporate Affairs and others
                      as relevant when the decision for the helpline to be transferred to Patient Affairs
                      office and when it has ceased.

8.   Post Emergency

     8.1     The Operations Director will:

                Stand down the emergency team
                Organise a de-briefing session for the team
                Write up reports as appropriate
                Follow up issues from de-briefing session/s
                Arrange external support for callers and team members as appropriate.




             K:\ Clin Gov\emergency helpline protocol.doc




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