Incident Report Form (Version 14)

Transcription

1 Incident Report Form (Version 14) Instructions: If you become aware of an incident you should let your line manager know as soon as possible then report the incident by providing an answer for every question in sections 1 to 12 on this form and deliver it to the relevant Executive Director for the incident within one working day of the incident actually happening. The Executive Director will ensure that this Incident is allocated to an Incident Owner who will be responsible for carrying out any necessary investigations. Section 13 - the allocation of an incident owner will be completed by an Executive Director. 1 Person Reporting the Incident or the Alert 1.1 Name of Person reporting the Incident or Alert. 1.2 Tick ANY of the boxes to show how you, the person reporting this incident, was involved in the incident Assisting with care Directly delivering care Overall responsibility for the person(s) involved in the incident or alert Informed of the incident or alert Witness to the incident Reporter of the incident or alert Involved in the lead up to the incident or alert (please describe) 1.3 Date that this form is being completed (dd/mm/yyyy) 2 Department or Team Please tick ONLY ONE of the following to show which team was involved in the incident Management Inpatient Unit Hospice at Home Administration and Clerical Information Technology Psychological Therapies And Wellbeing Estates, Domestic, Catering and Ancillary Community Macmillan Team Day Hospice Specialist Multidisciplinary Team Community Investment Crew Fundraising Team Volunteers Commercial Medical Home Care Human Resources Finance Page 1 of 10

2 3 Location and Time of the Incident 3.1 Where did the Incident happen?. 3.2 On what date did the incident happen? (dd/mm/yyyy) 3.2 At what time of day did the incident happen? (dd/mm/yyyy). 4 Safeguarding If the incident involved a safeguarding please tick to show if it involved adults or children? (Notify the CQC Manager of any Safeguarding issue within 24 hours of the report) Children s safeguarding No Safeguarding Adult safeguarding 5 Category of the Incident Tick ONLY ONE of the following boxes to show which category that this incident best fits. Environment and Health and Safety Fire Accident Information Governance and Record Keeping IT Security Failure to Obtain Consent Healthcare Record Missing Healthcare Record Inadequate No Access to Medical/Clinical Documentation Confidentiality/ Data Protection Breach Security (including theft) Intruder Security False Alarm Vandalism Forced Entry Theft Facilities/Environment Healthcare Record Misabled Healthcare Record Not Signed/Dated Care Plan Assessment Inadequate/Missing/Illegible Referral Inadequate/Missing/Illegible Documentation Lost or Misplaced Property Bogus Staff Member Fraud or Deception Violence Aggression Harassment Verbal Abuse Dangerous Weapon Page 2 of 10

3 Physical Abuse Racial Sexual Organisational or Strategic Strategic Allegation Against HC Professional Bullying Alleged Abuse Co-ordination and Communication Ward / Unit Closure Financial Fraud or Deception Safeguarding (Notify the CQC Manager of any Safeguarding issue within 24 hours of the report) Verbal Abuse Physical Abuse Racial Sexual Staffing Issues Inadequate Levels Inadequate Skill Mix Concern Over Competence Equipment or Infrastructure Failure of Device/Equipment Delay to Provide Equipment to the User IT Equipment Failure Deprivation of Liberties (DoLS) Bullying Alleged Abuse Inadequate Supervision Acting Beyond Scope of Practice Lack/Unavailability of Device/Equipment User Error of Device/Equipment Wrong Device/Equipment Used Telecommunications Failure Clinical Falls (Note: If any type of fall was involved enter the Patients Waterlow and Falls Assessment scores in section 5 below) Falls from unrestricted windows Fall on Inpatient Unit Fall in the community Page 3 of 10

4 Clinical - Pressure Ulcer Pressure ulcer community patient (Notify CCG) Patient admitted with Pressure Sore (within 72 hrs. of admission) (Notify CCG) Patient Developed Pressure Sore on Unit (72 hrs. post admission) (Notify CCG) If the Patient was admitted with, or developed a pressure sore within 72 hours of admission then record where the patient was referred from (if from hospital then state hospital AND ward): Source of Referral.. Tick one box to show the grade of sore: Clinical - Infection Control Needle stick Injury (If so, tick as appropriate) Staff Patient Other Failure to Decontaminate Equipment Unsafe Inappropriate Clinical Environment Unsafe Inappropriate Clinical Waste Issue Where an infection has occurred tick a box to show the type of infection: MRSA(Notify CCG) C-Diff(Notify CCG) E-Coli Bloodstream(Notify CCG) MSSA Acute encephalitis Acute infectious hepatitis Acute Poliomyelitis Anthrax(Notify CCG) Botulism(Notify CCG) Brucellosis Cholera(Notify CCG) Diphtheria Infection Developed within our Care Reported Infection Acquired Elsewhere HCAI listed on part 1 of death certificate Outbreak of infection Enteric Fever (typhoid or paratyphoid fever) Food poisoning Haemolytic Uracmic Syndrome (HUS) Infectious bloody diarrhoea Invasive group A streptococcal disease Legionnaires disease Leprosy(Notify CCG) Malaria Measles(Notify CCG) Meningococcal septicaemia Mumps Page 4 of 10

5 Clinical - Other Injury to patient Ward Closure(Notify CCG) Patient wandering or absent Breakdown in communication or co-ordination relating to clinical matters Clinical Complications Suicide or suicide attempt Allergic reaction Clinical - Community specific dog/household pets car breakdown lone working, unable to locate staff unhygienic environment Clinical - Medication related Prescribing illegible prescription incorrect or inappropriate prescription no signature Dispensing label error wrong medicine/strength Administration wrong patient wrong medicine wrong dose wrong formulation wrong frequency/time Monitoring and advice adverse drug reaction wrong/omitted verbal or written advice Delay failure to appropriately resuscitate Unexpected or suspicious death Patient self-harm Chaperone issues Patient dignity issue Discharge issue Blood transfusion issue Concern over DNACPR order unsafe environment inadequate support failure of care/care home failure of care/social care allergy not recorded Dosset Box Issue No Prescription wrong quantity delay/problem obtaining medication wrong route medicine omitted expired medicine allergy recorded but treatment given no record of administration failure to monitor side effects failure patient to follow directions Page 5 of 10

6 Medicine Security medicines obtained by theft or deception controlled drug issue delivery/transport medication issue Other medication related and never events Failure to monitor and respond to oxygen saturation (NEVER EVENT) (Notify CCG) Inappropriate administration of daily oral methotrexate (NEVER EVENT) (Notify CCG) Maladministration of Insulin(NEVER EVENT) (Notify CCG) Maladministration of potassiumcontaining solutions(never EVENT) Opioid overdose of an opioid-naïve patient(never EVENT) (Notify CCG) incorrect storage medicines missing/unaccounted for medicines found loose/not given medicines key issue Overdose of midazolam during conscious sedation(never EVENT) (Notify CCG) Wrong gas administered Wrong route administration of oral/enteral treatment (NEVER EVENT) (Notify CCG) Wrongly prepared high-risk injectable medication(never EVENT) (Notify CCG) Home Oxygen Patient Transferred or Discharged with No/Incorrect Medication/Prescription If none of the Categories above describe the Incident then please describe the type of Incident or Alert:.. 6 Controlled Drugs Whatever Category the incident was a Controlled Drug involved? YES / NO (please delete as appropriate) 7 Pressure Sore and Falls Assessment Scores If the incident DID NOT involve any type of pressure ulcer or fall then you do not need to enter anything for this section. If the incident involved any type of pressure ulcer then enter the patient s Waterlow scores from their time of admission and their most recent score. If the incident involved any type of fall then enter the patients Waterlow AND their falls assessments scores both at the time of admission and the most recent score. Patients Waterlow Score Score On Admission Score at time of Incident Patients Falls Risk Assessment Score (Tick as appropriate) Low Medium High Low Medium High Page 6 of 10

7 8 Description of Incident Please give a brief description of the incident remembering to include the most important facts. DO NOT include the names of any patients or members of the public, but you can record the name of a member of staff. (Recording staffs names where appropriate helps us in assurance of professional practice in accordance with national guidance on re-validation). Page 7 of 10

8 9 Severity of Harm Please tick ONE BOX only in this section to show how severe any actual harm was as a result of this incident. It is important that you tick a box for the harm that actually happened, not for any harm that you think could have happened. No harm No harm or loss of any type happened. (If no harm happened then, in the section below write a brief account of how harm was avoided) Insignificant Impacts on the person involved in this incident The person required some first aid. Info. Governance Impacts: Only a single individual affected. Strategic or Organisational Impacts: Negligible service deficit, Minor non-compliance No impact on care. Minimal disruption to activity. No long term consequences. Financial Impacts: Loss of less than 5k. Minor Impacts on the person involved in this incident: The person required medical treatment or hospital admission for up to 2 days. Emotional distress. Info. Governance Impacts: Less than 5 people affected. Strategic or Organisational Impacts: Single failure to meet internal standards or follow protocol. No impact care. No long term consequences Financial Impacts: Loss of 5K - 25K Moderate Impacts on the person involved in this incident The person required hospital admission for more than 2 days absence. Semi-permanent injury or emotional trauma. : Some local media interest that may not go public Serious potential breach with risk assessed high e.g. unencrypted clinical records lost. Up to 20 people affected. Strategic or Organisational Impacts: Repeated failures to meet internal standards or follow protocols Minimal impact on public health and social care Impact on organisation absorbed with significant level of intervention Minimal long term consequences Financial Impacts: Loss of 25K- 100K Major Impacts on the person involved in this incident: There was a single death, or permanent disability or emotional injury. : Local media coverage. Serious breach with either particular sensitivity or up to 1000 people affected. Strategic or Organisational Impacts: Notable service deficit, Major non-compliance. Financial Impacts: Loss of 100K 500k Catastrophic Impacts on the person involved in this incident: There were multiple fatalities, or multiple permanent disabilities or emotional injuries. : National media coverage. Serious breach with potential for ID or personal record theft or over 1000 people affected. Strategic or Organisational Impacts: Gross failure to meet standards Major impact on care. Major long term consequences Financial Impacts: Loss of More than 500k If you ticked any box to show any harm did happen then please describe how harm was caused: Brief Account of how harm was prevented or caused on this occasion: Page 8 of 10

9 10 Probability of this Incident happening again Please tick ONE BOX only in this section to show in your best opinion, how likely it is that an incident like this will happen again. Very Unlikely Repeat of this Incident is rare. There is a less than 5% chance of a similar incident happening again. (That means that out of 20 possible times that this incident could happen again, it will happen less than once or it will not happen at all). Unlikely Based on current systems then a repeat of this incident is unlikely. There is a less than 10% chance of a similar incident happening again. (That means that out of 20 possible times that this incident could happen again, it will happen twice). Fairly Likely Based on current systems then a repeat of this incident is fairly likely. There is between an 11% and 50% chance of a similar incident happening again. (That means that out of 20 possible times that this incident could happen again, it will happen between 3 and 10 times). Likely Based on current systems then a repeat of this incident is likely. There is between a 51% and 90% chance of a similar incident happening again. (That means that out of 20 possible times that this incident could happen again, it will happen between 11 and 18 times). Almost Certain Based on current systems then a repeat of this incident is almost certain to happen again. There is between a 91% and 100% chance of a similar incident happening again. (That means that out of 20 possible times that this incident could happen again, it will happen between 19 and 20 times). 11 Future Prevention and First Aid 11.1 Has action been taken to prevent harm resulting from a similar incident in the future? No Yes. If so then please give a brief description of the preventative action here 11.2 Was a First Aider involved? No Yes. If so please include a summary of the first aid that was given. Page 9 of 10

10 12 Details about the Person involved in the Incident 12.1 Persons gender Male Female 12.2 Persons Date of Birth (dd/mm/yyyy) Persons Name: Persons NHS Number:. Please check you have answered all sections correctly and pass this form to your line manager. The rest of this form will be completed by an Executive Director and a Business Administrator 13 Incident Owner (Executive Directors use only) In order to record these details on the QPOP database for Incidents the appropriate Executive Director must name an Incident Owner who will be responsible for carrying out any post-incident actions, investigations or notifications. Name of Incident Owner..... Check whether the incident is a never event or is a CCG notification, if so arrange notification. Please pass this form to your Business Administrator for entry into the QPOP Database. 14 Recording the Incident on QPOP Using the details in sections 1 to 11 on this form record this Incident in the QPOP Database. Once the incident has been saved use the Action Deadlines button on the QPOP on screen form (see figure 1) to print a report on the incident risk score and action deadlines and provide it to the allocated Incident Owner. Enter the QPOP ID number here to link any future documentation QPOP Unique ID Number for this Incident.. Figure 1 Action Deadlines Button on QPOP Incidents Database All further actions and information handled by the incident owner, up to and including closure of this incident, should be recorded directly in the QPOP database in the sections appropriate to this Incident. Page 10 of 10