ICS INCIDENT REPORTING POLICY

Transcription

1 ORG 04 Policy Number Purpose Of Document Target Audience ICS INCIDENT REPORTING POLICY This document sets out the ICS policy for reporting and managing incidents. The policy sets out generic good practice with 2 supporting SOPs for PULSE and one for TNS All workers Version V1.1 Author Karen Matthews-Shard Date of Approval November 2011 Published Date 02/12/2011 Lead Director Review Frequency Karen Matthews-Shard Annually Last Reviewed August 2016 Next Review Date August 2017 Risk And Risk:Potential communication risk as there is one Resource generic policy and two different approaches for Implications reporting and managing incidents. Associated Strategies and SOPs Equality Impact Assessment (EIA) Form Resources: Training Risk Management Strategy Clinical Governance strategy Risk assessment SOP PULSE reporting and grading incidents SOP TNS/SNG reporting incidents SOP EIA completed by the author of this policy and attached as an appendix

2 Document History Version Date Changes made/comments By whom Draft v 1 27/07/11 Changes made following K. Matthews- Shard comments concerning font and use of colons Draft v 2 09/09/11 All changes made. Inserted Document History sheet. Policy format changed as agreed. Now a generic group policy with 2 SOPs reflecting PULSE workers and TNS/SNG workers. K. Matthews- Shard Draft v 3 26/09/11 Policy checked and sent to KMS. K. Matthews- Shard Draft v 3 07/10/11 KMS changes made K. Matthews- Shard Final 08/11/11 Scottish Regulator included K. Matthews- Shard V1.1 Nov 2012 V1.1 Sept 2013 V1.2 V1.2 V1.2 V1.2 V1.2 Sept 2014 Sept 2014 May 2015 August 2015 August 2016 Annual review Annual review Annual review Welsh legislation added NMC Guidance added Annual Review Annual Review KNF/KMS KNF/KMS KNF/KMS KNF/KMS KNF KNF/SJ KNF/VM 2

3 Table of Contents Section Contents Page No. 1. Policy standards 8 2. Definitions 8 3. Roles and responsibilities Supporting national policies, guidance and legislation Reporting and managing incidents generic good practice 13 Equality and diversity 13 Assessment of risk 13 Reporting to statutory bodies 13 Record keeping 15 Recourse to a disciplinary procedure 15 Immediate action following an incident 16 Reporting, timescales and grading an incident Investigation of incidents and Root Cause analysis 17 Root cause analysis 18 Investigating an incident 18 Communication with and support for ICS workers 19 Communicating with and support for victims, Clients, 08 families and perpetrators Learning from incidents 19 Media management 19 Incidents which involve care partners 20 Governance Training Implementation 21 Consultation 21 Ratification 21 Dissemination 21 Audit/Monitoring Associated policies References 22 Appendices Appendix Equality Impact Assessment form 24 A Appendix PULSE reporting and grading incidents. SOP 25 B Appendix TNS/SNG reporting incidents. SOP. 31 C Appendix D Regulatory Guidance on reporting incidents 35 3

4 About Independent Clinical Services (ICS) Group ICS consists of a number of trading companies, each providing services within core niche areas of the health and social care industries. Therefore, as this document is a Group Policy, the Policy herein applies to all trading companies detailed below: Pulse Staffing Limited (Pulse) Pulse recruits health and social care professionals for temporary and permanent jobs in the UK and abroad. Pulse is the UK s leading independent provider of staff bank management services and provides specialist care packages to individuals in their own home or community setting. As an approved supplier to the NHS, Pulse holds contracts with NHS trusts, private organisations and local authorities nationwide. Pulse also works with hospitals globally, specifically within in Australia, New Zealand, North America, the Middle East and across Europe. Pulse places candidates - medical, scientific and nursing staff, allied healthcare professionals, social workers, support workers and carers - in posts appropriate for their training and experience. Pulse Staffing consists of a number of Pulse brands delivering staffing solutions and health and social care services globally, with a UK branch network and overseas offices, key brands include; Pulse Community Healthcare Management of packages of care to support/ enable individuals to live independently Pulse Nursing & Care, Pulse Critical Care, PULSE Specialist Nursing, Pulse Theatres, Pulse@Home - provision of all categories and grade of nursing & midwifery staff Pulse Doctors Provision of all specialty and grade of doctor including Psychiatry, Acute and GP Pulse Allied Health & Health Science Services Provision of all categories and grade of AHP & HSS staff (including Physiotherapy, Radiography, Speech and Language Therapy and Pharmacy) Pulse Staffing Partners, incorporating end-to-end management of complete staff banks Pulse Social Care Provision of all categories of unqualified social care staff Pulse Social Work provision of all specialty of qualified social work staff Frontline Staffing (FL) FL is a dedicated division of PULSE, committed to managing short-notice and hard-to-fill vacancies on both a temporary and permanent basis across the spectrum of health and social care categories of staff 4

5 Thornbury Nursing Services (TNS) Established in 1983, TNS is one of the UK s leading independent nursing agencies. Providing skilled nurses on a temporary or permanent basis to NHS Trusts and private sector clients throughout England and Wales. The TNS mission is simple: To provide the best professional solution to meet the requirements of each of our clients whilst recognising and rewarding the exceptional skills and efforts of our nurses. TNS delivers an exceptional service to both patients and clients by ensuring every nurse represented meets the most rigorous professional standards. TNS team of specially trained recruiters (themselves qualified nurses) personally interview and select nurses across the country using a strict method of competence-based assessment, ensuring that every nurse meets the highest expectations in terms of professional accreditation, competency, attitude and personality. Scottish Nursing Guild (SNG) Established in 1995, SNG, as part of Independent Clinical Services Ltd, is one of Scotland s leading independent nursing agencies, providing skilled nurses on a temporary basis to major NHS Trusts and private sector clients throughout Scotland and Northern Ireland. SNG s ability to respond promptly to staffing needs makes the service a invaluable resource in maintaining effective nursing coverage, with unparalleled commitment to providing nurses who meet the highest professional standards. SNG provides appropriately skilled health care assistants, operating department practitioners and qualified nursing staff to cover staffing shortages both short-term and ongoing. SNG provides temporary nursing staff to both NHS Trusts and private sector clients throughout Scotland. SNG s procedures and standards fully conform to or exceed the regulatory requirements in each territory. Thornbury Community Services (TCS) Thornbury Community Services (TCS) is part of Thornbury Nursing Services, which was first established in Thornbury Nursing Services is a large independent nursing agency providing commissioned and staffing solutions, covering the whole of England and Wales. TCS supply Registered Nurses (RNs) and Health Care Support Workers (HCSWs) to Clinical Commissioning Groups (CCGs), case managers and private individuals providing care for clinically complex patients in their own homes. 5

6 Hobson Prior Hobson Prior International is an award winning provider of staffing services for the medical device, drug discovery and clinical development community in Europe. Since 2002, we have been working exclusively within the life sciences industry, supporting organisations seeking to engage with exceptional professionals within the functional disciplines of clinical operations, medical affairs, pharmacovigilance, quality assurance and regulatory affairs. All our consultants specialise in a specific life sciences discipline and combine in-depth industry knowledge with an ethical and proactive sourcing approach to deliver the right solution for each client. Asclepius Asclepius is the only healthcare recruitment consultancy in the UK to give you access to six distinct, expert companies to best serve every medical specialty, along with managed services, under one roof. We re committed to helping improve patient care within the NHS by offering truly extraordinary temporary and permanent recruitment services to our clients and candidates. Maximma Maxxima is an established recruitment agency operating under two successful brand names; Labmed Recruitment and Swim Recruitment. Maxxima operates predominantly within the Healthcare and Social Services sectors. As well as offering traditional recruitment solutions to their clients, Maxxima runs a number of successful Master Vendor contracts, providing the NHS with a robust Vendor Managed Solution able to provide large scale cost savings whilst still retaining the expert knowledge and attention to detail associated with more specialist agencies in the market. 6

7 ICS Health & Wellbeing (ICS H&W) Pulse H&W is one of a few organisations in the UK offering a fully integrated health and wellbeing service that can be tailored to suit the needs of individuals and local communities. We have extensive experience of providing large-scale health improvement services for public and private sector organisations. By creating an approach that incorporates innovative technology, strong operational management and effective engagement, we use our expertise and wide range of skills, to provide a high quality and efficient solution for commissioners and long-term health benefits for individuals. Commissioners can choose to work with us across all, or a selection of our four core elements: 1. Health and wellbeing hub and interventions 2. Community outreach 3. Training 4. Social marketing campaigns 7

8 1. Policy standards 1.1 Within ICS there is a culture that supports safety and openness. All workers report incidents, accidents, near misses and potential incidents through the DATIX system so that steps are taken to improve the safety of the clients and workers. 1.2 Through a dynamic system of reporting and managing incidents the organisation is able to identify areas of potential risk at an early stage, and take action to improve working practice across the organisation. 1.3 ICS commitment to safety is delivered by everyone within the organisation through the understanding: Importance of timely incident reporting Significance of effective incident management Need to cooperate in the investigation of incidents, within the agreed timescales Value of incident reviews to establish the root cause and facilitate organisational wide learning Importance of involving clients and their families. This is a group generic policy which is supported by two Standard Operating Policies (SOPs). PULSE reporting and grading incidents and TNS/SNG reporting incidents. Copies of both these SOPs may be found in Appendix B and C. 2. Definitions 2.1 Definitions relevant to this policy are set out in table 1. Table 1: Definitions An incident Includes the terms untoward incident, near miss, adverse incident or accident. These are where an act, omission or undesired circumstance or event results, or had the potential to result in an unintended or undesirable outcome, harm, loss or damage. This may involve clients, workers, members of the client s family, property or equipment. The term incident includes issues related to but not exclusively related to: Working practices Client safety Health and safety Fire Theft Emergency situations Loss of information or data or data security breaches Violence/aggression from clients or their family against Any worker and vice versa. 8

9 An Adverse Incident A Serious Untoward Incident Root Cause Analysis (RCA) Contributory factors Reporting of Injuries, Diseases and Dangerous Occurrence (RIDDOR) An accident A Near Miss or No Harm Incident A Prevented Harm Incident A Hazard A Dangerous Occurrence Violence and Aggression at work Is any incident, occurrence or accident, related to clinical or nonclinical care, which has or could have resulted in an injury, or near miss to a client, visitor or worker. An incident may be: A complaint related to clinical or non-clinical care An event not in compliance with ICS routine operation Property or equipment damage Equipment failure Physical aggression or verbal threats. All workers must consider this fundamental definition when deciding to submit a report but if in doubt to report the incident. I Is an event that caused serious or catastrophic harm. Is a technique employed during an investigation that systematically considers the factors that may have contributed to the incident and seeks to understand the underlying causal factors. Are factors that contributed to or had an influence on the incident occurring. These are incidents including those involving an ICS worker that results in: Death, major injury Hospital admission over 24 hours or more than 3 days Absence from work. Is commonly defined as an unplanned event, which may or may not result in injury or damage. It is clear from this definition that it is not essential for injury to have been sustained or for damage to have occurred for an accident to happen. However, an accident is also defined as an unforeseen event resulting in harm or serious injury requiring a visit to the GP, Accident and Emergency or hospital admission. Is by definition an accident and must be regarded as a warning that a problem exists and that positive action is required. With a near miss the potential for harm exists if the event had occurred under slightly different circumstances. This means that the same immediate and basic potential causes of the accident are in place but on this occasion the outcome is limited to the events occurrence without resultant injury or damage. Because of the potential for harm, all these Incidents should be investigated at department level in the same way as accidents. Is an incident where a client or worker was prevented from an injury or harm by the action of another person. Is a general term for anything that has the ability to cause injury. Is something that happened that did not result in an injury, but which clearly could have done. Is defined as any incident in which a worker is verbally abused, threatened or assaulted by a client or member of the public in circumstances relating to his/her employment. Violence is 9

10 3. Roles and responsibilities defined as any incident where a worker is abused, threatened or assaulted in circumstances relating to their work, involving an explicit or implicit challenge to their safety, well-being, or health. 3.1 The overall organisational roles and responsibilities are set out in the policy document, ORG1 Policy for Drafting, Approval and Review of Policies and SOPs. 3.2 ICS acknowledges that reporting and managing incidents through the DATIX system is the responsibility of all its workers. The following table outlines the responsibilities of the key people involved in the effective reporting and management of incidents. Table 2: Roles and responsibilities relating to this policy Role Clinical Director Responsibilities He/she: Nominates an appropriate member of staff to lead grades 4 and 5 incident investigations. See PULSE Reporting and Grading an Incident SOP Ensures all incidents are investigated within agreed timescales Ensures there are appropriate systems to undertake: o A monthly incident trend analysis o A review of serious untoward incidents (SUI) o Implementation of the SUI investigation recommendations o The approval of actions identified to reduce the likelihood and occurrence of incidents o The dissemination and implementation of lessons learned o The monitoring of agreed actions o The review of the effectiveness of action taken to reduce the likelihood and occurrence of incidents Ensures a full cycle of communication in relation to the management of incidents from front line service level to the Senior Management Team and back to front line workers Identifies incidents that require reporting to external bodies such as the Health and Safety Executive, Care Quality Commission (CQC), Regulation Quality Improvement Agency, Northern Ireland (RQIA), Health Care Improvement Scotland(HIS).NHS Commissioning Board. ) Identifies when incidents require joint management for instance with NHS Acute Trusts, Mental Health Trusts, GPs and identifies a nominated ICS lead to undertake this joint working 10

11 Individual worker Monitors trends in incidents and highlights issues in relation to incidents that require escalation Ensures lessons learned are disseminated and implemented throughout ICS Monitors compliance with this policy and associated SOPs. To be aware of ICS Incident policy and PULSE SOP reporting and managing incidents and TNS SOP reporting incidents and ensure compliance with them. Report incidents, as soon as they occur or as soon as they become aware of an incident Inform their Line Manager/appropriate other as soon as possible. Prepare a statement of events for all level 4 and level 5 incidents as soon as possible after the event at the latest before the end of the working day. Report all other incidents within 3 days Report to their Line Manager/appropriate other if they are absent from work for more than 3 days as a result of an incident to ensure it is reported as a RIDDOR incident Take appropriate remedial action to reduce the risk and likelihood of the incident recurring or prevent further deterioration Co-operate in identifying the root causes of an incident and the implementation of any required changes to practice Take part in training, including attending updates so that skills and familiarity with the procedures are maintained Maintain a high level of record keeping practice at all times Abide by their professional standards Access regular supervision and support in line with local procedures. 4. Supporting national policies, guidance and legislation 4.1 This policy is supported by legislation and national guidance as set out in Table 3. Table 3: National policies, guidance and legislation supporting reporting and managing incidents. Act, policy, guidance Reporting of Injuries, Diseases and Dangerous Occurrence (RIDDOR) regulations 1995 updated England Scotland and Wales. Explanation These health and safety regulations require employers to report certain occupationally acquired injuries and diseases to the Health and Safety Executive. Certain workplace occurrences must also be reported. The regulations include strict timescales for reporting- failure to comply is an offence. See section for a list of RIDDOR reportable incidents. 11

12 The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (Northern Ireland) Health and Safety at Work Act 1974 England, Scotland, Wales and Northern Ireland. Health and Safety at Work (Amendment) Northern Ireland Data Protection Act 1998 (DPA98.) Safe Today Safer Tomorrow (NHS QIS 2006) Scotland. Care Quality Commission Essential standards of quality and safety. March Regulation and Quality Improvement Authority (RQIA) Northern Ireland Social Care and Social Work Improvement Scotland (SCSWIS) September 2011 (Known as the Care Inspectorate.) Northern Ireland Adverse Incident Centre (NIAIC) Safety Notice CCSIW Care and Social Services Inspectorate Wales Places a legal duty on: Employers Self-employed people People in control of premises To report work-related deaths, major injuries or over-three-day injuries, work related diseases, and dangerous occurrences (near miss accidents). All workers have the right to work in places where risks to their health and safety are properly controlled. The Health and Safety at Work Act creates legal obligations for staff and employers on ensuring this, including undertaking risk assessments to identify risks and to put in place preventative measures. As above. This Act provides a framework that governs the processing of personal information in relation to living individuals. It identifies eight data protection principles that set out standards for information handling. A breach of this Act constitutes a serious incident. Sets out suggestions for an effective incident reporting system. Regulator standards. The Regulation and Quality Improvement Authority (RQIA) is the independent body responsible for monitoring and inspecting the availability and quality of health and social care services in Northern Ireland, and encouraging improvements in the quality of those services. The reviews undertaken by RQIA are based on the 2006 Quality standards for health and social care. In 2009 the duties of the Mental Health Commission were also transferred to RQIA. The independent regulator of social care and social work services across Scotland. They regulate, inspect and support improvement of care, social work and child protection services for the benefit of the people who use them. Guidance for reporting adverse incidents is contained in this Safety Notice, distributed in Northern Ireland only. The independent regulator of social care and nurse agencies across Wales. They regulate inspect and support improvement of care, social work and child 12

13 CSSIW Regulation 28 NMC Raising Concerns: Guidance for nurses and Midwives. March 2015 Disclosure and Barring Service protection services for the benefit of the people who use them. Guidance for employers of Notification of Serious Injury and other incidents. This document provides guidance for nurses and midwives in raising concerns (including whistleblowing) and the process to follow. This service helps employers and manages to understand their legal duty in making a referral to the Disclosure and Barring Service (DBS) when one of their workers or volunteers has harmed or poses a risk of harm to a child or vulnerable adult. 5. Reporting and managing incidents key actions and generic good practice 5.1 Equality and diversity Under the Race Relation (Amendment) Act 2000, ICS has a statutory duty to set out arrangements to assess and consult on how their policies and functions impact on race equality, in effect to undertake Equality Impact Assessments (EIA) on all policies and SOPs. The Equality Act October 2010 demands a similar process of Equality Impact Assessment in relation to disability. An EAI must be completed by the author of this policy using the checklist provided in Appendix A. See also the ICS Equality and Diversity policy. 5.2 Best Practice This section sets out best practice in reporting, incidents, adverse incidents, accidents, near misses and potential incidents whether in a clinical or non-clinical environment, in a clients home or any other establishment that provides care. 5.3 Assessment of risk Assessment of risk and planning are integral to incident reporting and management and all workers are expected to contribute to these processes. Following an incident a risk assessment must be undertaken and action taken to reduce the likelihood of the incident recurring. The aim is to reduce the likelihood to the lowest, reasonably practicable category. When prioritising resource, action should be first targeted at reducing the likelihood of those incidents with the highest level of severity, or where an incident of a low severity may impact on a high number of persons Risks that are significant to ICS and clients or may be difficult to manage should be entered on the ICS risk register so that there is corporate awareness and monitoring. 5.4 Reporting to statutory and other bodies 13

14 5.4.1 Table 4 sets out a list of incidents and the appropriate reporting body to whom ICS reports certain incidents in order to safeguard the clients safety All external reporting must be reported to the Clinical Director first. This list is indicative only. Table 4: List of incidents and appropriate to reporting body. Incident Reported to: ICS is legally required to report all RIDDOR Regulations of 1995 now 2013 accidents and incidents, defined in Injuries or absences arising out of the regulations to the Health and work activities as detailed in the RIDDOR Safety Executive, within ten days of Policy. the accident occurring. Incidents involving failed medical Medicines and Healthcare products devices. In the case of commissioned or contracted services where a Serious Untoward Incident (SUI) has occurred the Clinical Director is the person responsible for informing and updating the appropriate body. Clinical Director may deem some incidents need to be reported to commissioning board Incidents as a result of infectious diseases. Incidents of a criminal nature. Incidents related to poor professional performance. Care Quality Commission Essential standards of quality and safety. March 2010 England Scottish Care Inspectorate Regulatory Agency (MHRA). Reported to the: Commissioner Lead for the contracted service Next of Kin or the client of the care package. The Commissioning Board Reported to the new national public health service, or in the interim, the Health Protection Agency. Police. Professional regulatory bodies. Regulator. Regulator. Regulation and Quality Improvement Authority (RQIA) CSSIW Care and Social Services Inspectorate Wales (2004) 'The Regulation and Quality Improvement Authority (RQIA) is the independent body responsible for monitoring and inspecting the availability and quality of health and social care services in Northern Ireland, and encouraging improvements in the quality of those services.' The reviews undertaken by RQIA are based on the 2006 'Quality standards for health and social care'. In 2009 the duties of the Mental Health Commission were also transferred to RQIA. The independent regulator of social care and nurse agencies across Wales. They regulate inspect and support improvement of care, social work and child protection 14

15 services for the benefit of the people who use them Types of incidents reportable under RIDDOR include: Any fracture, other than to the fingers, thumbs or toes Any amputation Any injury likely to lead to permanent loss of sight or reduction in sight Any rush injury to the head or torso causing damage to the brain or internal organs Serious burns (including scalding) which: Covers more than 10% of the body Causes significant damage to the eyes, respiratory system or other vital organs Any scalping requiring hospital treatment Any loss of consciousness caused by head injury or asphyxia Any other injury arising from working in an enclosed space which o Leading to hypothermia, heat-induced illness o Requiring resuscitation, or o Requiring admittance to hospital for more than 24 hours 5.5 Record keeping Accurate record keeping is vital in all elements of care provision and incident management. Effective record keeping often speeds up the sometimes stressful aspects of incident reporting and management. For full details on the requirements of record keeping, please refer to the ICS Record Management policy All incidents should be logged onto the DATIX system. In case of litigation incident forms must be retained for a period of 10 years following the closure of an incident. 5.6 Recourse to disciplinary procedures Within ICS there is a fair blame culture with an emphasis on discovering and addressing the root causes of an incident through thorough analysis of all the contributory factors. There may be instances where recourse to the disciplinary process is required if: There is a deliberate failure to report or an unreasonable delay in reporting an incident Misconduct and serious misconduct i.e. fraud, physical assault, corruption, breach of confidentiality, or where the incident is repeated on several occasions During an incident investigation there is evidence that the incident was due to an action deemed reckless, deliberate or as a result of gross negligence There is an attempt to deliberately mislead an incident investigation If punitive action is necessary, as a result of a disciplinary investigation, it must be seen to be fair and reasonable and not influenced by the outcome of the incident, or the position or profession of the worker. No disciplinary action will be taken as a 15

16 result of incident reporting against workers who have followed ICS policies and procedures and exercised reasonable judgement. Where disciplinary procedures are required the Human Resources department will be involved at the earliest opportunity. The disciplinary procedure will not be used as part of any investigation process unless there is: Clear evidence of blatant malpractice Breaches of professional standards of conduct Grossly unprofessional errors A complete disregard for the safety of others Malicious intent to harm Theft Fraud or any other criminal or malicious acts. Follow up action may take the form of retraining, disciplinary procedures or reporting to a professional regulatory body. 5.7 Immediate actions following an incident. Actions are as follows: Prevent a recurrence of the incident, which may include an item of equipment being removed or the client removed from the area of the incident in order to create a safe environment Provide or arrange any first aid or medical care as needed Retain and keep all evidence, preferably in the same condition, as it was at the time of the incident If help is required it must be called as soon as possible, this may include the police, fire, ambulance and/or Line Manager/appropriate other If an incident has occurred to a client that they are unaware of then they should be advised sensitively as soon as possible, after the incident. Workers who feel they need the support of their Line Manager/ appropriate other to do this should call their Line Manager/appropriate other as soon as possible and wait for them to attend the incident, prior to discussing this information with the client Statements must be taken as soon as possible after the event and before the end of the shift. See the ICS Record Management policy for guidance. 5.8 Reporting, timescales and grading of incidents There are two different approaches to reporting, timescales and grading of incidents one for PULSE workers and one for TNS/SNG workers. The SOPs that support this policy are set out in Appendix B PULSE Reporting and Grading of Incidents and in Appendix C TNS Reporting Incidents 5.9 Appeal: If the complainant is dissatisfied with the outcome of the incident Investigation they are able to follow the appeal process An appeal can be lodged with the Clinical Director by writing to Karen Matthews- Shard, Turnford Place, Great Cambridge Road, Turnford, Hertfordshire, EN10, 6NH Karen Matthews-Shard will review the investigation and will contact you in writing with the outcome. Once Karen Matthews-Shard has given the outcome there is no 16

17 further avenues for appeal with ICS and appeal to external bodies will be necessary if the complainant continues to be dissatisfied with the outcome. 6. ICS investigation of incidents and Root Cause analysis 6.1 This section applies to incidents categorised in Appendix B Reporting and Grading of Incidents for PULSE workers. Investigations into incidents where there are TNS/SNG workers will be carried out, in partnership, with the Client organisation and in line with their policies and SOPs. 6.2 The aim of the investigation is to understand what happened, identify how future incidents may be prevented and ensure that the conclusions in the final report are fair, evidenced and reasoned. The investigation is intended to: Find out all the facts regarding the sequence of events that led up to the incident Determine what was well managed Determine what (if anything) went wrong and identify any issues of concern Identify the root causes that led or contributed to the incident occurring Make recommendations to address the root causes identified. All aspects of the investigation must be recorded on DATIX 6.3 Root Cause Analysis (RCA) RCA is a structured and systematic review of an incident to establish: The chronological series of all events leading up to the incident The causal factors that may have contributed to the incident RCA is a structured investigation that aims to identify the true cause of a problem, and the actions that are necessary to either eliminate or significantly reduce the risk. The approach to RCA is that the investigator asks the question 'Why?' about each significant event and condition in the emergent picture in the accident sequence, and keeps asking 'Why?' until its usefulness is exhausted and the actions that are necessary are identified that either eliminate or significantly reduce the risk. The six steps involved in undertaking a RCA include: Identify scope of investigation and gathering Information Prepare a chronology of events Problem identification Problem exploration Identify safety and quality improvements Generate the RCA Report, Improvement Plan and sharing the lessons learned A RCA must be undertaken for all level 4 and 5 incidents. As part of the investigation, contributory factors will be analysed. See Table 5. Factors to be considered. Table 5: RCA factors to be considered 17

18 Factors to be considered in all clinical reports Client factors Communication factors Organisational/Strategic/Policy/Care Coordination, Record Keeping Individual /professional Team and Social Equipment and Resource Other factors to be considered as appropriate Task Engagement Environmental factors - working conditions Education and Training 6.4 Investigation of an incident Investigation of an incident may include some or all of the following processes: Interviews with the key individuals involved Interview with the person affected (where appropriate) Interview with any witnesses Inspection of the location of the incident Inspection of any equipment involved Examination of any physical evidence available Review of appropriate policy or Standing Operational Policy (SOP) Review of the personnel healthcare records. All interview transcripts should be uploaded to DATIX If it becomes clear that an incident is in relation to safeguarding vulnerable adults or children, the incident must be referred to the local safeguarding teams for further investigation and action. All investigations must be completed and attached as a linked document to the Datix incident report within 2 months. Less complicated incidents are expected to be completed in a shorter period of time. 6.5 Communication with and the support for ICS workers ICS is committed to developing a culture which allows workers to raise concerns through appropriate channels, particularly in relation to client safety. Where workers wish to raise concerns about client safety they must consult the ICS Whistle Blowing policy. Following a reported incident, regardless of severity level it is essential that the workers are appropriately supported by the Line Manager/appropriate other, involved in any subsequent investigation and advised of the investigation outcomes and recommended changes to practice. 6.6 Communicating with and the support for victims, clients, families and perpetrators ICS expects that following any incident those involved in the incident, workers and clients will be offered information and support commensurate with the level of the incident. Where applicable and with the consent of the client, families and carers, the perpetrator is also offered the relevant level of support and information The NPSA guidance to the NHS, to which ICS is committed, Being Open means communicating client safety incidents with clients and their carers and informing all third party contacts following an incident. The basic principles underlying any communications are the principles of: Acknowledgement 18

19 Truthfulness, timeliness and clarity of communication Apology. Information and support will be provided by the Line Manager/appropriate other but in the event of level 4 or level 5 incidents, the Clinical Director will identify a designated lead, to support the family. 6.7 Learning from incidents It is essential that all workers feel able to report incidents openly and feel supported during incident management so that lessons can be learnt. Learning from incidents is disseminated in a number of ways, depending on the level of urgency. Some learning is provided through the dissemination of alerts via the managers. Other methods of dissemination are made via posting information on the Intranet, newsletter or training events. 6.8 Media management In the event that an incident occurs that attracts media attention the process of liaising with the media is by the Clinical Director and/or Chief Executive. Under no circumstances should any worker enter into discussions with the media unless nominated by the Chief Executive or Clinical Director. 6.9 Incidents which involve care partners There may be an occasion when there is an incident which involves more than one care provider. When this occurs there will be full partnership working to enable the other care providers to learn from incidents as well. Information will be shared on a need to know basis and according to the ICS Records Management policy Governance All incidents are reported monthly to the Governance Committee and quarterly to the Senior Management Team. Clinical quality and safety meetings will be held across the business, for group discussion with current incidents and complaints, lessons learnt and dissemination of information Investigation of workers Workers involved in an incident are required to participate in an investigation and if necessary could be subject to a disciplinary or breach of contract process. The process required will depend on the type of worker that was involved in the incident. In ICS there are two types of worker: Workers on an employment contract: PAYE Workers on a terms of engagement contract: LTD Company, agency workers, self employed. 19

20 ICS have different responsibilities for the different types of workers and therefore terminology used through the investigation process is different. The table below illustrates the differences required. Stage (if applicable) Stop the workers working (if applicable) Investigation Stage Disciplinary Stage Workers on employment contract Suspend workers pending investigation Invite workers to investigation meeting Workers to attend disciplinary meeting Workers on terms of engagement Remove workers from all future shifts pending investigation Invite workers to investigation meeting Workers to attend Breach of Contract Meeting 7. Training 7.1 ICS will enable their workers to participate in training in the effective management of incidents. This will be backed up in local induction programmes. This is a mandatory requirement upon commencement of employment with ICS. ICS workers are also expected to attend regular updates. The training will be proportionate and relevant to the roles and responsibilities of each worker. 7.2 The delivery of training is the responsibility of the Line Managers/appropriate others. It is the responsibility of the central training team to organise and publicise educational sessions and keep records of attendance. 8. Implementation plan 8.1 For consultation, ratification and dissemination of this policy see the policy for drafting, approval and review of policies and SOPs. Policy ORG This policy will be implemented through: Communication of the policy to all relevant workers Communication of the policy to all stakeholders Raising awareness and understanding of the policy and related processes throughout the organisation through committee meetings, ICS worker s meetings, ICS pages, the website and general communication Through ICS induction programmes and related training. 8.3This Policy will be implemented as part of the review of Governance mechanisms and policies in ICS during 2011 and will be reviewed on a yearly basis. The Clinical Director will ensure the dissemination of this policy across the organisation. 20

21 8.4 Audit and Monitoring 8.4.1The Clinical Director will monitor compliance with this policy. See also Policy Author s responsibilities table 2 in the ICS Policy drafting, approval and review of policies and SOPs. Policy ORG Processes for monitoring the effectiveness of this policy include: Audits of specific areas of practice Evidence of learning across the organisation Incidents reporting procedure Appraisal and Personal Development Plans (PDP) The audit will: Identify areas of operation that are covered by this policy Set and maintain standards by implementing new procedures, including obtaining feedback where the procedures do not match the desired levels of performance Highlight where non-conformance to the procedures has occurred and suggest a tightening of controls and adjustment to related procedures Report the results to the Governance Committee via the Clinical Director Specific elements for audit and monitoring are the: Investigation of incidents in a manner appropriate to their severity Standard of documentation Completion of relevant action plans Aggregation of incidents and claims Frequency and appropriateness of logging incidents Management of incidents according to timescales Evidence of structured learning across ICS. ICS will regularly audit its incident reporting and management for compliance with this policy. 8.5 This policy replaces all other ICS incident recording and management policies. 9. Associated policies Policy for drafting policies and SOPs Records management policy Health and Safety policy Whistle-blowing policy Infection prevention and control policy Safeguarding Vulnerable Adults policy Safeguarding Children policy Resuscitation policy Reporting and Managing Complaints policy 21

22 10. References 10.1 Reporting of Injuries, Diseases, and Dangerous Occurrences Regulations RIDDOR) Health & Safety 1995 updated Executive Organisation with a Memory, Department of Health National Service user Safety Agency (NPSA) Seven Steps to Service user Safety, National Service user Safety Agencies, National Service user Safety Agency (NPSA) Being Open, National Service user Safety Agencies (NPSA) National Service user Safety Agency. September 2005., 10.5 Data Protection Act HMSO A First Class Service Quality in the new NHS: DoH Safety First, DoH An organisation with a memory Report of an expert group on learning from adverse events in the NHS chaired by the Chief Medical Officer: DoH Serious Untoward Incident (SUI) Reporting Guidance. NHS London Memorandum of Understanding Investigation Patient Safety Incidents (DoH 2004) Seven steps to patient safety National patient safety agency, February Doing Less Harm, National Patient Safety Agency, National Patient Safety Agency Being open when patients are harmed NPSA September National Patient Safety Agency (NPSA) Seven Steps to Patient Safety. The full reference guide. Available at April The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (Northern Ireland) 1997, Health and Safety at Work Act 1974 England, Scotland, Wales and Northern Ireland Health and Safety at Work (Amendment) Northern Ireland Data Protection Act 1998 (DPA98) Safe Today Safer Tomorrow (NHS QIS 2006) Scotland Care Quality Commission Essential standards of quality and safety. March Regulation and Quality Improvement Authority (RQIA) Northern Ireland Social Care and Social Work Improvement Scotland (SCSWIS) September Northern Ireland Adverse Incident Centre (NIAIC) Safety Notice Raising Concerns: Guidance for Nurses and Midwifes NMC (March 2015) Disclosure and Barring Service Guidance on how to make a referral - (DBS

23 Appendix A: Additional paper to be completed as part of the ratification process: Equality impact assessment (EIA) checklist for the Incidents Management Policy. To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. Yes/No Comments 1. Does the procedural document affect one group less or more favourably than another on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Age Disability - learning disabilities, physical disability, sensory impairment and mental health problems 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are there any exceptions valid, legal and/or justifiable? 4. Is the impact of the procedural document likely to be negative? No No No No No No No No No No No No 5. If so can the impact be avoided? N/A 6. What alternatives are there to achieving the procedural document without the impact? N/A 7. Can we reduce the impact by taking different action? N/A If you have identified a potential discriminatory impact of this procedural document or need advice please refer it to the Clinical Director, together with any suggestions as to the action required to avoid/reduce this impact. 23

24 Appendix B: PULSE Reporting and Grading Incidents SOP. 1. Reporting and grading incidents standard 1.1 Within the organisation there is a culture that supports safety and openness. All PULSE workers report incidents, accidents, near misses and potential incidents so that steps are taken to improve the safety of service users and workers. 1.2 PULSE commitment to safety is delivered by everyone within the organisation through understanding the: Importance of timely incident reporting Significance of effective incident management Need to cooperate in the investigation of incidents,within the agreed timescales Value of incident reviews to establish the root cause and facilitate organisational wide learning Importance of involving service users and their families. 2. Reporting and grading incidents SOP general points 2.1 An incident includes the terms untoward incident, near miss, adverse incident or accident. These are where an act, omission or undesired circumstance or event results, or had the potential to result in an unintended or undesirable outcome, harm, loss or damage. This may involve service users, PULSE workers, members of the service user s family, property or equipment. The term incident includes issues related to but not exclusively related to: Working practices Service user safety Health and safety Fire Theft Emergency situations Loss of information or data or data security breaches Violence/aggression from service users or their family against a PULSE worker and vice versa. 2.2 Assessment of risk Assessment of risk and planning are integral to incident reporting and grading and workers are expected to contribute to these processes. Following an incident a risk assessment must be undertaken and action taken to reduce the likelihood of the incident recurring. The aim is to reduce the likelihood to the lowest, reasonably practicable category. When prioritising resource, action should be first targeted at reducing the likelihood of those incidents with the highest level of severity, or where an incident of a low severity may impact on a high number of persons. See ICS Risk Assessment SOP. 24

25 Risks that are significant to PULSE workers and/or service users or may be difficult to manage should be entered on the risk register (DATIX) so that there is corporate awareness and monitoring. 3. Reporting an incident 3.1 Reporting incidents This SOP sets out a series of actions to be taken to achieve a consistent approach to the reporting and grading of an incident. This SOP is a formal document and must be complied with by all PULSE workers and must be read in conjunction with the ICS Reporting and Managing Incidents Policy ORG: Table 1 sets out a summary flowchart for the required action for PULSE workers to follow in the event of an incident, adverse incident, accident, near miss and potential incidents whether in a clinical or non-clinical environment, in a service user s home or any other establishment that provides care. 25

26 Table 1: A summary of the required action for PULSE workers to report an incident 1. Prevent a recurrence of the incident. 2. Provide or arrange any first aid or medical care as needed. 3. Retain and keep all evidence. 4. If help is required it must be called as soon as possible, this may include the police, fire, ambulance and/or Line Manager/appropriate other. 5. If the service user is unaware of the incident then they should be advised sensitively as soon as possible, after the incident. 6. Statements must be taken as soon as possible after the event and before the end of the shift. 7. All incidents are classified according to five levels of severity. An immediate assessment of the incident grade must be undertaken to allow PULSE workers to progress the incident. See Table 2.Incident Grading. 8. Incidents must be logged on Datix within 3 working days of the incident except those graded at grades 4 and 5 which must be reported on Datix within 1 working day of the incident. 9. Incidents assessed as grades 4 and 5 must be reported immediately to the Clinical Director through the Line Manager/appropriate other or out of hours to the on call manager. 10. Reporting incidents on Datix is not dependent on the time of day therefore reporting is expected at all times. If Datix is not available, see appendix 1 for a copy of the template. Only facts are to be recorded, including dates and times. Do not record opinions. 11.Accurate record keeping is vital in all elements of care provision and incident management Incident Classification/grading report forms must not be of kept incidents the service user s clinical notes. These should be held centrally by the Clinical Director. In case of litigation incident forms must be retained for a period of 10 years following the closure of an incident. 26