Development and Ratification of a Policy, Protocol, Procedure or by fsd65350

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									                                                       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



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   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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   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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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

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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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   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

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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

 Responsibility               Action
 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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      APPENDIX B – INCIDENTS THAT SHOULD ALWAYS BE REPORTED
                           (TRIGGER LIST)

The following must always be reported. NB this is not an exhaustive list, and should be read in
conjunction with Appendix 9 - response to major clinical incidents.

        Accidents involving any person on the Trust‟s premises, however small, regardless
         of whether or not any treatment is required
        Absence of signed consent form
        Loss of instruments in theatre
        Unmarked site, or incorrectly marked site
        Inappropriate surgery performed
        Any event affecting multiple patients
        Absconding of patients
        Incidents relating to Information Governance
        Slips, trips and falls
        Incidents where patients are transferred between wards (more than 3 moves)
        Untoward outcomes
        Unexpected death
        Suicide
        Serious self-harm
        Drug errors and other medication incidents
        Cervical screening incidents
        “Rogue” staff
        Injury or ill-health suffered as a result of handling patients or any item
        Contact with bodily fluids – needlesticks
        Contact with harmful chemicals or spillages
        Expression or act of violence or aggression
        Loss of patient property
        Breach of security i.e. Break-in, theft of property
        Breach of confidentiality
        Damage to Trust property, including premises, fixtures, equipment, furniture etc, whether
         accidental or deliberate
        Fire (actual or false alarm)
        Incidents relating to any vehicle on Trust premises, or involving a Trust-owned vehicle off
         Trust premises
        Record –related incidents, including records not being available
        Procedure or protocol-related incidents, including failure to follow these
        Incidents related to Radiology regulations - requires the notification to be made directly to the
         appropriate authority (Healthcare Commission) appointed for these Regulations.


Maternity Services
The Maternity Service Risk Management Strategy contains a list of additional incidents that must be
reported for the Maternity Service. These incidents are also listed on laminated cards for easy
reference, and are available in Maternity.




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                    APPENDIX C – NOTIFIABLE EXTERNAL AGENCIES


 Report to:                                      Circumstances:
 Health and Safety Executive                     For any incidents to a patient, employee, visitor,
                                                 contractor, volunteer or trespasser involving the
                                                 work environment or work activity.
                                                 See Appendix D

 Environment Agency                              Major contamination of the environment

 Environmental Health Agency                     Adverse incident involving food poisoning
                                                 originating in or being transferred through the
                                                 Trust

 Medicines and Healthcare Products Regulatory    Any incident involving a medical device that has
 Agency (MHRA)                                   led or could lead to if it happened again –
                                                 death, life threatening injury, or illness,
                                                 deterioration in health, necessity for medical or
                                                 surgical intervention, unreliable test results
                                                 leading to inappropriate diagnosis or therapy

 NHS Estates                                     For incidents relating to fire, buildings, plant and
                                                 non-medical equipment reports should be made
                                                 to NHS Estates via Estates manager on ex
                                                 4700

 Healthcare Commission                           Incidents in breach of radiology regulations

 General Practitioner                            Death or major injury to a patient

 Coroner                                         Sudden unexpected death of a patient
                                                 Suicide of patient
                                                 Death as a result of an accident at work

 Police                                          Death or injury where the person in charge
                                                 considers there to be unusual or suspicious
                                                 circumstances
                                                 Theft of Trust property
                                                 Malicious damage to Trust property
                                                 Violent or aggressive events where the person
                                                 in charge considers it necessary for a police
                                                 presence
                                                 Arson

 Fire service                                    Any external information relating to Fire Safety

 STEIS                                           Serious untoward incidents – report through
                                                 manager or On-Call Director




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                      APPENDIX D - What is reportable under RIDDOR?
  (The Reporting of Injuries Diseases and Dangerous Occurrences Regulations 1995
                                      (RIDDOR)
    As an employer, The Trust has legal duties under RIDDOR that require the Trust to report and
               record some work-related accidents by the quickest means possible.

Reportable deaths and major injuries

Deaths or Major injuries
If there is an accident connected with work and an employee, or self-employed person working on
the premises, or a member of the public is killed this must be reported without delay. Please contact
your manager, General Manager or on-call Manager, who can report the incident by telephoning the
Incident contact Centre (ICC) on 0845 300 99 23 or complete the appropriate online form (F2508).
A Trust incident form should be completed and accompany the RIDDOR form when sent to the
Patient Safety Manager.

Reportable major injuries are:
        Fracture, other than to fingers, thumbs and toes;
        Amputation;
        Dislocation of the shoulder, hip, knee or spine;
        Loss of sight (temporary or permanent);
        Chemical or hot metal burn to the eye or any penetrating injury to the eye;
        Injury resulting from an electric shock or electrical burn leading to unconsciousness, or
         requiring resuscitation or admittance to hospital for more than 24 hours;
        Any other injury: leading to hypothermia, heat-induced illness or unconsciousness; or
         requiring resuscitation; or requiring admittance to hospital for more than 24 hours;
        Unconsciousness caused by asphyxia or exposure to harmful substance or biological agent;
        Acute illness requiring medical treatment, or loss of consciousness arising from absorption of
         any substance by inhalation, ingestion or through the skin;
        Acute illness requiring medical treatment where there is reason to believe that this resulted
         from exposure to a biological agent or its toxins or infected material.

Reportable over-three-day injuries
If there is an accident connected with work (including an act of physical violence) and an employee,
or a self-employed person working on Trust premises, suffers an over-three-day injury it must be
report it to the enforcing authority within ten days.

An over-3-day injury is one which is not "major" but results in the injured person being away from
work OR unable to do their full range of their normal duties for more than three days.

Contact the Patient Safety Manager or Health & Safety Advisor and complete an incident form as
soon as possible.

Reportable disease

If a Trust employee is suffering from a reportable work-related disease, then it must be reported to
the enforcing authority.




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Reportable diseases include:
        Certain poisonings;
        Some skin diseases such as occupational dermatitis, skin cancer, chrome ulcer, oil
         folliculitis/acne;
        Lung diseases including: occupational asthma, farmer's lung, pneumoconiosis, asbestosis,
         mesothelioma;
        Infections such as: leptospirosis; hepatitis; tuberculosis; anthrax; legionellosis and tetanus;
        Other conditions such as: occupational cancer; certain musculoskeletal disorders;
         decompression illness and hand-arm vibration syndrome.
        A full list of reportable disease

Reportable dangerous occurrences (near misses)

If something happens which does not result in a reportable injury, but which clearly could have done,
then it may be a dangerous occurrence which must be reported immediately.

Reportable dangerous occurrences are:
      Collapse, overturning or failure of load-bearing parts of lifts and lifting equipment;
      Explosion, collapse or bursting of any closed vessel or associated pipework;
      Failure of any freight container in any of its load-bearing parts;
      Plant or equipment coming into contact with overhead power lines;
      Electrical short circuit or overload causing fire or explosion;
      Any unintentional explosion, misfire, failure of demolition to cause the intended collapse,
       projection of material beyond a site boundary, injury caused by an explosion; Accidental
       release of a biological agent likely to cause severe human illness;
     Failure of industrial radiography or irradiation equipment to de-energize or return to its safe
       position after the intended exposure period;
     Malfunction of breathing apparatus while in use or during testing immediately before use;
     Failure or endangering of diving equipment, the trapping of a diver, an explosion near a diver,
       or an uncontrolled ascent;
     Collapse or partial collapse of a scaffold over five metres high, or erected near water where
       there could be a risk of drowning after a fall;
     Unintended collision of a train with any vehicle;
     Dangerous occurrence at a well (other than a water well);
     Dangerous occurrence at a pipeline;
     Failure of any load-bearing fairground equipment, or derailment or unintended collision of
       cars or trains;
     A road tanker carrying a dangerous substance overturns, suffers serious damage, catches
       fire or the substance is released;
     A dangerous substance being conveyed by road is involved in a fire or released;
     The following dangerous occurrences are reportable except in relation to offshore
       workplaces: unintended collapse of: any building or structure under construction, alteration or
       demolition where over five tonnes of material falls; a wall or floor in a place of work; any
       false-work;
    Explosion or fire causing suspension of normal work for over 24 hours;




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        Sudden, uncontrolled release in a building of: 100 kg or more of flammable liquid; 10 kg of
         flammable liquid above its boiling point; 10 kg or more of flammable gas; or of 500 kg of
         these substances if the release is in the open air;
        Accidental release of any substance which may damage health.

When do I need to make a report?

Although the Regulations specify varying timescales for reporting different types of incidents, it is
advisable to ring and report the incident as soon as possible by calling the Incident Contact Centre
on 0845 300 99 23.

In cases of death, major injury, or dangerous occurrences, you must notify the enforcing authority
without delay, most easily by calling the Incident Contact Centre on 0845 300 99 23.

Cases of over-three day injuries must be notified within ten days of the incident occurring.

Cases of disease should be reported as soon as a doctor notifies you that your employee suffers
from a reportable work-related disease.

What records do I need to keep?

Records must be kept of any reportable injury, disease or dangerous occurrence. This must include
the date and method of reporting; the date, time and place of the event; personal details of those
involved; and a brief description of the nature of the event or disease.

Records can be kept by:
        keeping copies of report forms in a file;
        recording the details on a computer;
        using an Accident Book entry;
        maintaining a written log.
If the incident is reported online or by telephone, a copy will be sent to the Trust – amendments can
be made to the record if the reporter does not feel that the report is fully accurate.

What is the Incident Contact Centre (ICC)?

The ICC is a „one-stop‟ reporting service for work-related health and safety incidents in the UK. It
was established on 1 April 2001 and is a primarily a call centre, open from Monday to Friday
between 8:30am and 5:00pm. If you wish to speak to an ICC operator, just call 0845 300 99 23. All
information will remain confidential.

You can also report by completing an interactive form which automatically sends you a copy for your
records.
Reports are also accepted via email or post to the ICC.

How do I contact the ICC?
        By phone: 0845 300 99 23 (local rate)
        Online: HSE RIDDOR - Report online
        By email: riddor@natbrit.com
By Post: Incident Contact Centre, Caerphilly Business Park, Caerphilly CF83 3GG




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                               APPENDIX E Incident Assessment Process

1. Assess the actual (or potential) consequence of the incident
Using table below, assess the actual or potential consequence of the incident against columns A, B
and C in turn. Grade the consequence as the highest category scored across columns A, B and C.
                                                 CONSEQUENCE OF THE INCIDENT
                                          A                               B                                  C
                       Actual or potential impact on patient,   No. of people affected    Actual or potential impact on the Trust
                                 staff or visitor(s)            or potentially affected
                                                                     at one time
     Catastrophic      Death                                    Over 50                   National adverse publicity
                                                                                          Severe loss of confidence in the
                                                                                          organisation
                                                                                          Litigation expected >£1M
                                                                                          Extended service closure
     Major             Major permanent harm                     16 - 50                   National adverse publicity
                                                                                          Major loss of confidence in the Trust
                                                                                          Temporary service closure (> 1 week)
                                                                                          Litigation £50K - £500K
     Moderate          Semi-permanent harm (up to 1             3-15                      Local adverse publicity
                       year) including:                                                   Moderate loss of confidence in the
                       Known or suspected health care-                                    Trust
                       associated infection which may                                     Temporary service closure (up to 1
                       result in semi-permanent harm                                      week)
                                                                                          Increased length of stay 8-15 days
                                                                                          Increased level of care 8 – 15 days

     Minor             Non-permanent harm (up to one            1-2                       Litigation <£50K
                       month) including known or                                          Increased length of stay 1-7 days
                       suspected health care associated                                   Increased level of care 1-7 days
                       infection which may result in non
                       permanent harm
     Insignificant     No obvious harm                          1-2                       Minimal impact
                                                                                          No service disruption


2.           Select the Likelihood Rating
Using the Likelihood table below, select the likelihood of the incident recurring
               LIKELIHOOD
               Score     Description                  Guidance
               5         Almost certain               Expected to occur daily, weekly, or many times a month.
               4         Likely                       Expected to occur in most circumstances
               3         Possible                     May recur occasionally
               2         Unlikely                     Probably won‟t happen again but it is possible
               1         Rare/impossible              The event may occur in exceptional circumstances


3.           Plot the consequence against the likelihood on the chart below to identify the “Colour”
             category

                         Insignificant         Minor                   Moderate            Major                  Catastrophic
 Almost certain          Green                 Amber                   Dark Amber          Red                    Red
 Likely                  Green                 Green                   Amber               Dark Amber             Red
 Possible                Green                 Green                   Green               Amber                  Dark Amber
 Unlikely                Green                 Green                   Green               Green                  Amber
 Rare/impossible         Green                 Green                   Green               Green                  Green

4.           Take Action


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                                    Incident Management Process
This process applies at all times, and to all incidents, whether the incident occurs inside or
outside hours.
In the interests of patient safety, the Trust encourages openness and constructive criticism of clinical
care. During or following an incident, staff should actively seek to share learning in a constructive
manner using appropriate forums.

                 MAKE THE SITUATION SAFE

                 PROVIDE SUPPORT TO STAFF

                 NOTIFY THE INCIDENT

                 REPORT CRIMES (IF NECESSARY)

                 MANAGE MEDIA OR PUBLIC INTEREST AS APPROPRIATE

                 ALLOCATE LEAD INVESTIGATOR

                 DOCUMENT THE INCIDENT

                 INVESTIAGTE THE INCIDENT (Incident Investigation Form is included in Procedure
                  for Investigating Claims, Complaints and Incidents)

                 OBTAIN STATEMENTS FROM RELEVANT PERSONNEL

                 RECORD KEEPING – RECORD INFORMATION EITHER BY DIAGRAM,
                  PHOTOGRAPH OR WRITTEN DESCRIPTION

                 TAKE CORRECTIVE OR REMEDIAL ACTION

                 ENSURE ANY ACTION PLAN DEVELOPED IS IMPLEMENTED

                 PROCESS FAULTY EQUIPMENT

                 PROVIDE FEEDBACK TO STAFF

                 FORMAL REPORTS




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         Monitoring Compliance with and Effectiveness of Procedural
                             Documents Form

                                                   Incident Management Policy
Title of Procedural Document

Date                                               August 2008

Standards for Better Health (SfBH)
                                                   C1a Safety
relating to this document (if any)
NHSLA Standard related to this
                                                   5.1
document (if any)
Does the document fulfil the                                YES √                        NO
criterion of NHSLA and SfBH
          (please circle as appropriate)           If not, why not:




 1.     How will the document                                                       Other, please
        be monitored?                         Audit          KPI       Review         specify;
          (please circle as appropriate)                                          _______________
                                           Methodology:
                                           Daily monitoring of incident reporting by Patient Safety
                                           Manager
                                           Monthly reporting of incidents to assuring committees

 2.     What is the process for
        reviewing results of    Ongoing process monitoring quality of reported data, number
        monitoring?             of incidents reported, action plans, lessons learned and
                                           changes in practice

 3.     Who is responsible for
        conducting the                           Group / Committee                  Individual
        monitoring?                        Name / Title (also include position of individuals):
          (please circle as appropriate)

                                           Patient Safety Manager
                                           Governance Team

 4.     How often will the                                                          Other, please
        document be                         Monthly        6 Monthly   Yearly         specify;
        monitored?                                                                _______________
          (please circle as appropriate)   Comments:

                                           Ongoing




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                           Disseminating Procedural Document Form
                            Plan for Dissemination of Procedural Documents

Title of Document                      Incident Management Policy
Date finalised                         August 2008
Review Committee                       Clinical Governance Committee
Dissemination lead                     S A Shelton – Patient Safety Manager
(Print name and contact details)

Previous Document                                                       Yes
already being used?
If, yes in what format                 Trust Intranet
and where?
What action will be used               Replacement of previous documents in Governance section of Intranet.
to retrieve out-of-date
copies of the document:
                                           Dissemination Process
 Receiver (area /                                                                                 Format
                                    Process                Responsible          Timeline      (paper or electronic)
   ward / unit)
All departments                Send email with          Head of Governance    By 30/09/08     Electronic
                               Document attached




________________________________________________________________________________________________

                  Record of Dissemination of Procedural Documents
Complete this section of the form once the procedural document has been approved by
the appropriate committee.
Date of approval of the document
Date of review of the document

Receiver (area             Contact (area      Number of     Date
                                                                                       Comments
 / ward / unit)            / ward / unit)     copies sent complete




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                        Approving Procedural Documents Checklist


Title of Procedural Document
                                     Incident Management Policy
Author
                                     S A Shelton – Patient Safety Committee
                                     Clinical Governance Committee
Ratifying Committee / Group
                                     August 2008
Date of Submission


                                      Item                                          Complete
                                                                                       (YES / NO)
 1      Has the Procedural Documents Policy and its associated documents         Yes
        been consulted during the development of this document?
 2      Has the appropriate template been used?                                  Yes

        Has the South Warwickshire General Hospital NHS Trust Style Guide        Yes
        been used to develop this document?
 3      Have the appropriate committees / groups / individuals been consulted    Yes
        as to the appropriateness of the content of this document?
 3a     Please list these committees / groups / individuals:
        Clinical Governance Committee


 4      Has the Plan for Dissemination of a Procedural Documents form been       Yes
        completed and attached?
 5      Has an Equality Impact Assessment been undertaken?                       No
 6      Has the procedural document been attached?                               Yes
 7      Has the Monitoring Compliance with and Effectiveness of Procedural       Yes
        Documents Form been attached?

Author (sign off)
I declare that the information above is a true and accurate record
             Name                            Position                     Signature
S A Shelton                      Patient Safety Manager


Appropriate Manager for Subject (sign off)
I declare that I have overseen that development of this procedural document and believe all
appropriate matters have been addressed
             Name                          Position                     Signature




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