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PROCEDURE FOR THE INITIAL MANAGEMENT & REPORTING OF INCIDENTS AND NEAR MISSES
Prepared by:
Eve Scott
Responsible Area:
Risk Management Date Approved: COMMITTEE:-
2nd October 2006 Trust Board
Approved By:
Sign
Approval Information:
Print Name
Reference to Standards for Better Health Domain Core/Development standard Performance indicators
Version No. Approved:
One
Review Date:
October 2007
Department of Health 2004 Standards for Better Health First domain Safety Fourth domain Governance
Core Standard C1 C1B D1 C7B C8A
1. Number of incidents reported 2. Evidence of decrease in severity of incidents 3. Evidence of incident reporting from all areas of PCT
CONTENTS Section No. 1. 2. 3. 4.
Page No’s History of Document Policy Statement Associated Policies and Procedures Aims & Objectives
5.
Scope & Policy Guideline
6.
Standard Definitions
7.
7.1; Initial management of an incident: 7.1.1; All staff. 7.1.2; Line manager (responsible person) 7.1.3; Communication with patients/ carers/ service users 7.1.4; Retention of scene/ equipment 7.1.5; Secure all records 7.1.6; Completing an IR form. 7.1.7; Recording a violent incident. 7.1.8; Witnesses 7.1.9; Grading the incident. 7.1.10; Grade Red incidents 7.1.11; Where to send the completed form 7.2; 7.2.1; 7.2.2; 7.3 7.4;
General Guidance Notes re completing the form. All staff Line managers (responsible persons) RIDDOR reportable incidents Commence the investigation
8.
References & Bibliography
9.
Appendices Appendix 1; How to grade and classify an incident Appendix 2; Example of incident types and classifications. Appendix 3; Examples of incidents that should be reported in accordance with RIDDOR regulations a. Consultations with individuals/groups or subcommittees’
NICE Guidance Once NICE guidance is published, health professionals are expected to take it fully into account when exercising their clinical judgement. However, NICE Guidance does not override the individual responsibility of health professionals to make appropriate decisions according to the circumstances of the individual patient in consultation with the patient and/or their guardian or carer.
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Procedure for the Initial management and Reporting of an Incident
1. History of Document This is version 1 of the Procedure for the Initial Management and Reporting of an Incident
2. Procedural Statement.
This procedure lays out the process to be followed in order to • report an incident or near miss involving PCT staff, patients, contractor or visitor, premises or PCT systems and processes. • Manage an incident.
3. Associated Policies and Procedures Associated policies and procedures. This procedure is one of a set that underpin the Incident Reporting Policy. It should be used in conjunction with this policy and its associated policies and procedures, namely • Incident reporting policy • Serious Untoward Incident Procedure • Risk Management Strategy • Incident, Complaint and Claims Investigation Policy and Toolkit • Risk Assessment Policy and Toolkit • Emergency Plan • Whistle Blowing Policy • Media Handling Policy & Media Handling Procedure West Yorkshire Strategic Health Authority (WYSHA): Serious Untoward Incident Policy
4. Aims & Objectives The aim of this procedure is to ensure that any incidents that occur are managed in an effective and timely manner to minimise injury or damage and reduce the likelihood of a similar incident happening in the future
5. Scope & Policy Guideline It is one of a set of procedures that underpin the Kirklees PCT's Incident Reporting Policy and as such must be complied with by all directly employed staff of the two PCTs. It is offered to the independent contractors as 'best practice' for them to use as appropriate in their sphere of responsibility.
6. Standard Definitions Standard Definitions. A list of standard definitions has been appended to the Incident Reporting Policy. The reader is directed to them. Of particular relevance to this particular procedure are the following: • Incident: Any unplanned occurrence, which has given or may rise to actual or possible personal injury, patient dissatisfaction, property loss or damage, or damage to the financial standing or reputation of the PCT. • Near misses: Those incidents that did not lead to harm, but could have done. This definition is consistent with the terms ‘adverse health care event’ and ‘health care near miss’ first set out in An Organisation with a Memory.
7. 7.1 Management of an Incident Approval Committee: Version No: Date Approved:
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Procedure for the Initial management and Reporting of an Incident 7.1.2; Initial response to an incident: relevant line manager (responsible person) • Review immediate remedial action taken • Review arrangements to preserve the scene, deal with hazards and secure the safety of all individuals as appropriate. • Ensure that relevant records are secured and kept in a safe and confidential environment. • Ensure that equipment involved in an incident is quarantined; that is removed from service and kept securely. • Complete the Incident Report Form. • Inform Chief Executive, Director, occupational health (e.g. needle-stick injury), the Health & Safety, Risk Manager or external agency as required e.g. RIDDOR, HSE, MHRA. • Discuss a radiation incident with your Radiation Protection Supervisor who would notify the Radiation Protection Adviser at Bradford Medical Physics. 7.1.3; Communication with patients/ carers/ service users. Normally, communication with patients or clients and their relatives will be via the appropriate member of the operational staff eg District Nursing Sister. However, if an incident occurs that may attract media attention, every attempt should be made to contact and involve the communications manager as soon as possible. The communications manager will then, if necessary, manage communications with patients their relatives or carers, staff, the public and the media. • It is expected that the senior members of the care team will undertake the direct communication with patients and their families or carers. • Every effort must be made to inform the patients their carers or next of kin before the media and the general public. 7.1..4; Retention of scene/ equipment Once any immediate hazards have been removed, the scene of the incident must be preserved in the condition in which it ended after the incident until the relevant Manager has inspected it. Where practicable any equipment involved in the incident must be preserved (quarantined) in the condition in which it ended after the incident. Do not allow the equipment to be repaired or destroyed until it is known that it is no longer required for inspection. 7.1.5; Secure all records Identify all relevant records and secured them in a safe and confidential environment. 7.1.6; Complete an IR form. The form should be completed as soon as possible, or within 24 hours of an incident occurring or of you becoming aware of the incident. Failure to complete an incident form could lead to disciplinary action being taken. • • •
Sections 1 – 5 member of staff directly involved in the incident. If they are not able to complete the form, then their immediate line manager should complete the form. Sections 6 – 10 the line manager. In the case of a third party (patient, client, member of public or contractor) a member of staff will complete the form.
7.1.7; Recording Violent Incidents Approval Committee: Version No: Date Approved:
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Procedure for the Initial management and Reporting of an Incident The PCT must report all incidents of physical aggression against its employees to the NHS Security Services. In all cases the victim must be named on the incident form. Where practicable the aggressor should be named in the incident description. If the aggressor is injured a separate form should be completed. If more than one form is completed relating to the same incident, then ensure that each form is crossreferenced. 7.1.8; Witnesses Witnesses to an incident may be required to provide a written statement to be attached to a copy of the incident report. Statements should be written as soon as possible after the incident to enable witnesses to recall as much information as possible. Use the template in the Incident, Complaint and Claims Investigation Toolkit. Staff may want to seek advise from their union representative or other appropriate person before providing a statement. This is acceptable, but should occur in a timely fashion. If staff are asked to provide a written statement by an external organisation, they should inform their line manager as soon as possible and before the statement is provided in order that adequate support can be given to that member of staff. 7.1.9; Grade the incident. The person completing the incident report form must grade the incident, at the time of reporting, using the 'Five by Five' matrix (Refer Appendix 1 for instructions on how to use the matrix). If necessary they can obtain advice from their line manager (responsible person) or the Risk Management team. 7.1.10; Red Graded Incidents. If the incident is graded and found to be 'Red' according to the grading matrix, the person completing the form must follow the Serious Untoward Incidents Procedure. They should notify their Director and fax a copy of the incident report form to the Chief Executive's Safehaven fax 01484 466139. 7.1.11; Where to send the completed form Return the completed form to the risk management team based at PCT Headquarters marked private and confidential. This should be done within 5 days of the incident. If this timescale cannot be met, then please contact the Health and Safety Risk Manager via 466000 and inform then of the incident and that a form is pending. 7.2;
General Guidance Notes on completing the form.
7.2.1; All Staff. • Use the report form to record ALL incidents, near misses and complaints • Record only known facts – do not record opinions • The report form (Sections 1-5) should be completed by the staff member most directly involved with the incident, or where that person is incapacitated, by a suitable witness. • The form should be passed to the person with designated responsibility for incident Approval Committee: Version No: Date Approved:
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Procedure for the Initial management and Reporting of an Incident • •
investigation (responsible person) and sections 6 – 10 completed. Please use a black ball point pen to write clearly, using block capitals where possible Death or serious injury must be reported immediately (details on the incident form) and the Serious Untoward Incident Procedure followed.
7.2.2; Line managers (responsible persons) signing off the form. The responsible person must ensure that:• Section 1 to 6 of the incident reporting form is completed by the staff member involved (this will form part of the contemporaneous record). • All parts (including the incident grading) of the above are completed. • It has been completed legibly. • Witness statements are obtained where necessary. They must be signed, dated, timed and they must be legible • Sign and date the form under Section 5 (staff) Section 6 (manager) • Any immediate action taken is recorded under Sections 6 - 10 • A photocopy / scan of the incident form is made and keep a copy in the appropriate place o Patient Record o Staff Record o Site Record • A copy of the incident report form is forwarded to the Risk, Health & Safety Manager • If the incident severity is graded higher than 5, then the responsible person will need to discuss with their Director within 1 week. 7.3 RIDDOR Incidents RIDDOR is the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (1995) and is a statutory element of Health and Safety requirements. Examples of RIDDOR Incidents are contained in Appendix 3 with further guidance available on the Health and Safety Executive Website www.hse.gov.uk. Should a RIDDOR reportable incident occur, the risk management team should be informed as soon as possible. 7.4; Commence the investigation. The line manager should commence the investigation in accordance with the Incident, Complaints and Claims Investigation Policy and using the appropriate tools from the Incident, complaints and claims investigation toolkit.
8. References & Bibliography
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Procedure for the Initial Management and Reporting of Incidents and Near Misses. page 6 of 15 Issue 1
Appendix 1: How to Grade & Classify an incidents Classification The incidents that can occur in any organisation are varied. One way of looking at incidents is to rank them according to their impact and likelihood of occurrence. It is the responsibility of the person reporting the incident to assess the level of risk, at the time of reporting, using the matrix below. The person completing the grading can be supported in this by their manager (responsible person). An incident is classified using the following 2 qualitative scales. The grading from each scale is multiplied together to rank the incident on the classification matrix. Likelihood Rating
5=Almost Certain 4=Likely 3=Possible
1=Rare
A persistent issue (more than once a week) Will probably occur (once or twice a month) May occur occasionally (once or twice per year for up to 3 years) Do not expect it to happen but it is possible (once every 3 to 5 years) Can’t believe this will ever happen (that is to say not in the next 5 years)
5=Catastrophic 4=Major 3=Moderate 2=Minor 1=Insignificant
Death or suspected murder Permanent injury, amputation, major damage Semi-permanent injury or damage Short term injury or damage No injury or adverse outcome
2=Unlikely
Impact / Consequenc e rating
Figure 1 Classification Matrix Most likely Impact/Consequences Likelihood of occurrence/ recurrence Almost certain Likely Possible Unlikely Rare
(5) (4) (3) (2) (1)
None (1)
Minor (2)
Moderate (3)
Major (4)
5 4 3 2 1
10 8 6 4 2
15 12 9 6 3
20 16 12 8 4
Catastrophi c (5) 25 20 15 10 5
Classification of Incident Very Low Approval Committee: Version No: Date Approved:
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Moderate
High
Procedure for the Initial Management and Reporting of Incidents and Near Misses. page 7 of 15 Issue 1 Appendix 2: Examples of Incident types and classes The following table gives examples of incident types and classes: This table is designed to help people classify risk, however it is not exhaustive or definitive. Certain incidents identified as 'moderate' may well, on investigation, fall into the major or minor categories according to individual circumstances. People are asked to use their discretion. Incident type VIOLENCE
Major/ Serious Damage to property
PHYSICAL
Rape
Death
Any Death on GP premises
SEXUAL ASSAULT RACIAL ASSAULT
Sexual assault
Sexual Harassment
Physical assault on the grounds of race.
PHYSICAL INJURY / ASSAULT OR WOUND (including pressure sore)
RIDDOR Injury
Racial Harassment not encompassing assault. 3 Day injury
SELF HARM
Moderate Minor damage to property
Injury requiring Trust treatment or specialist nursing advice. Death or serious injury to a patient or member of the public, which is alleged to be at the hands of a patient or a member of the public whilst on NHS property Suicide of a person currently receiving NHS care Serious Injury of a person currently receiving NHS care by deliberate self harm
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Minor Property disturbed but not damaged
No injury
Injury requiring immediate medical or nursing intervention eg suturing, but not admission to secondary care.
Damage to personal belongings
Injury requiring medical but not Trust treatment
Attempted injury
Verbal abuse/ threat/ harassment/ altercation between patients
Procedure for the Initial Management and Reporting of Incidents and Near Misses. page 8 of 15 Issue 1 *ABSCONSION SLIP
Of suicidal patient Of dangerous patient RIDDOR injury
TRIP
RIDDOR injury
FALL MANUAL HANDLING EQUIPMENT
Of sectioned patient not in class B Less than 3 day injury Less than 3 day injury
RIDDOR injury Over 2 metres RIDDOR injury RIDDOR injury or occurrence Failure of medical equipment resulting in death/major injury
*FOOD PRODUCTION AND SERVICE
FIRE ENVIRONMENT
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Of voluntary patient not in class B No injury Near miss Near miss
Less than 3 day injury
No injury
Less than 3 day injury Less than 3 day injury
No injury Near miss Minor injury Near miss
minor damage to property
Outbreak of poisoning
any failure of alarmed equipment Single alleged poisoning
Food well past its “use by date”
Foreign object in food
Staff smoking or spitting in kitchen or dining area Fire which results in casualties or major disruption to services Oxygen deprivation
Past “best before” date
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Tastes off
Damage to property
Staff able to put out
Too hot/cold Noisy Full of smoke or dust Persistent foul smell
Untidy Not kept in a clean condition Cramped Not enough light Lack of privacy
Procedure for the Initial Management and Reporting of Incidents and Near Misses. page 9 of 15 Issue 1 SECURITY
ELECTRICAL
Unauthorised person in restricted area. Theft of property. Unauthorised use of information systems. Break in to vehicle or building
Staff unable or unwilling to produce I.D. Unauthorised person attempting entry to restricted area. Vandalism. 3 day injury.
RIDDOR injury or occurrence.
Sparking when switched on.
Blows system fuse when switched on.
COLLAPSE OF STRUCTURE CONFIDENTIALITY
PEST CONTROL
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Near miss Defective or damaged equipment in use.
Static discharge received.
Adjacent equipment made live. SUBSTANCE (chemical or microbiological)
Suspicious person loitering on premises or near a vehicle.
RIDDOR injury or disease. Infection requiring prophylaxis.
3 day injury Spillage of harmful toxic, irritant, flammable, potentially infectious material.
Spillage of very toxic, corrosive, highly or extremely flammable, oxidising, explosive, highly infectious material. RIDDOR injury or occurrence Theft or loss of patient case notes or computers / laptops containing patient information
Minor damage. 3 day injury Confidential waste not placed in correct bag
Unauthorised passing of information to a third person. Infestation Sighting of single pest
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Near miss. Less than 3 day injury. Spillage of other substance causing a potential slipping hazard. Near miss.
Procedure for the Initial Management and Reporting of Incidents and Near Misses. page 10 of 15 Issue 1 WASTE DISPOSAL
CLINICAL
POOR PERFORMANCE / NEGLIGENCE SHARPS
INFECTION CONTROL
SUBSTANCE USE/ABUSE ON TRUST PREMISES MEDICATION ERROR
Clinical waste in household bin. Open clinical waste bag. Sharps container loose outside of Trust premises Clinical incident resulting in death/serious injury Patient dies or loses a limb or loss of function. Grade 4 pressure sore Inoculation by used needle. Cut by infected material. Serious unexplained outbreaks of infection or disease. Transmission of a serious infectious disease between an NHS staff member and a patient (HIV/Hep B) Use or supplying illicit substances without medical supervision. Resulting in death/serious injury
COMPUTER VEHICLE
Virus in network Write off
INFORMATION
Insufficient information given to G.P. or Trust following transfer. Patient record lost
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Confidential waste in clinical waste bag. Build up of waste not collected. Unforeseen/ unexpected occurrence from medical treatment/ clinical diagnosis. Patient suffers an injury that takes some time to heal.
Patient suffers an untoward injury that heals without loss of function.
Inoculation by clean needle. Cut by potentially infected material. Single person suffering from an infection
Any other substance abuse e.g. alcohol, glue, solvents Requires observation but not admission to general Trust. Virus in disk Repairable damage. Third party damage Inability to track down patient record immediately.
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No damage
Procedure for the Initial Management and Reporting of Incidents and Near Misses. page 11 of 15 Issue 1 Appendix 3 Examples of incidents that should be reported in accordance with RIDDOR regulations These are listed in Schedule 1 of RIDDOR, thus: 1. Death or major (RIDDOR) injury of staff or sub contractor as a result of NHS work activities reportable to the HSE, e.g: 2. fractures, except to fingers, thumbs or toes 3. amputation 4. dislocation of the shoulder, hip, knee or spine 5. loss of sight (temporary or permanent) 6. chemical or hot metal burn to the eye or any penetrating injury to the eyes 7. injury resulting from an electric shock or electrical burn, leading to unconsciousness or requiring 8. resuscitation or admittance to hospital for more than 24 hours 9. acute illness requiring medical treatment or loss of consciousness resulting 10. from the absorption of any substance by inhalation, ingestion or through the skin or exposure to a biological agent 11. Any other injury which: 12. leads to hypothermia, heat induced illness or unconsciousness 13. requires resuscitation or admittance to hospital for more than 24 hours or if he injured person is already in hospital for more than 24 hours or if the injured person is already in hospital then the injury would have resulted in admission for more than 24 hours “dangerous occurrence” reportable under the RIDDOR regulations Contact details’ www.HSE.gov.uk Health and Safety Executive Incident Contact Centre, Caerphilly Business Park, Caerphilly, CF83 3GG Tel
0870 1545500
Fax
0845 3009924
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