SERIOUS INCIDENTS (SIs) REPORTING POLICY and PROCEDURE

Transcription

1 SERIOUS INCIDENTS (SIs) REPORTING POLICY and PROCEDURE Version: Approved by: Final NHSW Quality and Patient Safety Assurance Committee Date approved: 2 nd November 2010 Ratified by: Date ratified: Name of originator/author: Lead Director Date issued for publication: Review date: Expiry date: Target audience: Date of Equality Impact Assessment Date of Equality Impact Scrutiny and Approval Quality and Patient Safety Assurance Committee 2 nd November 2010 Annie Coyle Karen Hunter Sandra Brennan Director of Clinical Development and Executive Lead Nurse November 2012 September 2012 September 2013 All Providers commissioned by NHSW & NHSW Staff. 14 th September th October 2010 This policy must be read in conjunction with: Worcestershire PCT (WPCT): Incident Reporting Policy West Midlands Strategic Health Authority (SHA): SI Reporting policy and Procedure. UK National Screening Committee: Managing Serious Incidents in the English NHS National Screening Programmes Guidance IF YOU WOULD LIKE THIS DOCUMENT IN OTHER LANGUAGES OR FORMATS (I.E. LARGE PRINT), PLEASE CONTACT THE COMMUNICATIONS TEAM ON OR COMMUNICATIONS@WORCESTERSHIRE.NHS.UK NHSW Serious Incidents (SIs) reporting policy and procedure Page 1 of 24

2 CONTRIBUTION LIST Key individuals involved in developing the document Name Designation Karen Hunter Head of Quality and Patient Safety. NHS Worcestershire Annie Coyle Quality and Patient Safety Co-ordinator NHS Worcestershire Circulated to the following individuals for consultation Name Designation Response Received Richard Stringfellow Head of Corporate Development No Rob Neil Information Governance Officer No Yvonne Buttery GP Appraisal Co-ordinator/Q&SA Administrator Yes Kath Garrad Complaints Manager No Lesley Way Patient Safety Manager, WPCT Yes Tracy Baker Health & Safety and LSMS Manager No Tony Hadfield Non-executive Director, NHSW Yes Carol Clive Nurse Consultant Infection Prevention and No Control Jane Freeguard Head of Medicines Management and Yes Pharmacy Stuart Bourne Consultant in Public Health No Ash Banerjee Consultant in Public Health No Sharon Buckley Emergency Planning Manager No Jonathan Leach Medical Director No Dr Frank Morgan Clinical Governance Lead Yes Lynda Dando Head of Primary Care No Chris Emerson Head of Acute Commissioning No Lynn Takavarasha Head of Community Services Commissioning No Sue Harris Lead Joint Commissioner (Mental Health Joint No Commissioning Unit) Trevor Neatherway Head of PBC Commissioning No Rosemary Williams SWCC Cluster Manager No Heather MacDonald Wyre Forest Cluster Manager No Andrea Cudd R&B Cluster Manager No Dr Anthony Kelly Chair, Clinical Senate No NHSW Serious Incidents (SIs) reporting policy and procedure Page 2 of 24

3 CONTENTS: EXECUTIVE SUMMARY INTRODUCTION PURPOSE SCOPE AND DEFINITION OF TERMS REPORTING & MANAGING SERIOUS INCIDENTS (SIs) REASONS FOR NHSW CONTACTING A PROVIDER ORGANISATION DUTIES/RESPONSIBILITIES MONITORING DISSEMINATION, IMPLEMENTATION AND ACCESS TO THIS DOCUMENT REVIEWING, UPDATING AND ARCHIVING OF THIS DOCUMENT REFERENCES GLOSSARY 17 Appendix 1 Grading of serious incidents 18 Appendix 2: NPSA Information resource to support the reporting of SIs 19 Appendix 3: Serious Incident (SI) Reporting Template 20 Appendix 4 Essentail Contact Details 22 Appendix 5- Grading and Timescales for Investigation 23 Appendix 6 Equality Impact Assessment Report Template 24 NHSW Serious Incidents (SIs) reporting policy and procedure Page 3 of 24

4 EXECUTIVE SUMMARY The NHS treats over 1 million patients every single day. Although the vast majority of patients receive very high standards of care on occasions serious incidents (SIs) occur. SIs in healthcare are relatively uncommon but when they occur NHS organisations and other providers have a responsibility to ensure that there are systematic measures in place for safeguarding people, NHS resources and reputation. This includes the responsibility to learn from these incidents in order to minimise the risk of them happening again and ensuring that such incidents are investigated and lessons learnt are shared appropriately. This policy establishes a clear approach to managing SIs. It is aimed at all staff working in NHS-funded care who may be involved in identifying and/or managing serious incidents. This includes NHS organisations, independent service providers (GPs, Dentists, Optometrists and Pharmacists), Nursing Homes and private providers in Worcestershire, all of whom should take appropriate steps to promote and protect patient safety, in the best interests of patients/clients/service users, staff, and the NHS as a whole. For the purpose of this policy, the term Provider refers to all organisations/individuals who are commissioned by NHS Worcestershire (NHSW) to provide NHS-funded care. It also provides guidance for all Providers who are involved in a SI spanning organisational boundaries. In this situation the organisations responsible for the patient s care at the time the incident occurred should co-ordinate and manage the SI investigation and reporting process. It is important that all organisations work together to manage SIs appropriately and sensitively to resolve all incidents. In order to do this it is recommended that a lead organisation must be agreed between all interested parties. This policy compliments but must not replace the robust incident reporting systems already in place within Provider organisations. It must not alter existing lines of accountability and does not negate the duty to inform the Police and/or other organisations or agencies where appropriate. NHSW Serious Incidents (SIs) reporting policy and procedure Page 4 of 24

5 1.0 INTRODUCTION 1.1 This policy states the processes for reporting, managing, investigating, analysing and learning from SIs. The ultimate aim is to reduce the risk of harm and identify learning opportunities for improving patient safety. 1.2 Providers are required to ensure that all SIs are reported to NHS Worcestershire (NHSW); in line with their contract requirements. They must assure NHSW that robust arrangements are in place to identify, investigate, and appropriately manage the impact of each SI and actions implemented to prevent recurrence. 1.3 NHSW will ensure that all information supplied by Providers will not be passed on or relayed to third parties except where it is required for investigation purposes or where required to under statutory obligations e.g. The Freedom of Information Act. Summary reports and statistical information which identify trends will be produced but any information identifying individual Providers will not be shared with third parties without first obtaining the permission of the Provider concerned. 1.4 NHSW is committed to improving communication amongst Providers and patients who have been harmed and expects all Providers to demonstrate being open, a principle which involves acknowledging, apologising and explaining what happened to patients and/or their carers involved in a patient safety incident. 2.0 PURPOSE The purpose of this policy and procedure is: 2.1 To explain the processes in place to ensure that NHSW is informed of all SIs within the services it commissions, irrespective of the Provider. 2.2 To increase the robustness of SI reporting by all Providers. 2.3 To clarify reporting lines to help strengthen the conduct, management and handling of investigations following an SI that occurs within NHSW. 2.4 To clarify roles and responsibilities in respect of SIs for all staff providing NHS-funded care. 3.0 SCOPE AND DEFINITION OF TERMS 3.1 This policy follows the new NPSA framework National Framework for Reporting and Learning from Serious Incidents Requiring Investigation (National Patient Safety Agency, 2010) making use of the new definition of a Serious Incident. It supports and encourages an open and honest culture supportive of continual learning. 3.2 A serious incident requiring investigation is defined as an incident that occurred in relation to NHS funded services and care resulting in: NHSW Serious Incidents (SIs) reporting policy and procedure Page 5 of 24

6 the unexpected or avoidable death of one or more patients, staff, visitors or members of the public permanent harm to one or more patients, staff, visitors or members of the public or where the outcome requires life-saving intervention or major surgical/medical intervention or will shorten life expectancy (this includes incidents graded under the NPSA definition of severe harm; Appendix 1) a scenario that prevents or threatens to prevent a provider organisation s ability to continue to deliver health care services, for example, actual or potential loss or damage to property, reputation or the environment a person suffering from abuse adverse media coverage or public concern for the organisation or the wider NHS 3.3 Never events The NPSA has designated a list of events that should never occur in NHS funded care. These are known as never events. When a never event occurs it always should be reported as an SI. The current, nationally agreed, Never event list is given below (subject to amendment on an annual basis): Wrong site surgery Retained instrument post-operation Wrong route administration of chemotherapy Misplaced naso-gastric or oro-gastric tube not detected prior to use Inpatient suicide using non-collapsible rails or whilst on one-toone observations Absconsion of a transferred prisoner from medium or high secure mental health In-hospital maternal death from post-partum haemorrhage after elective Caesarean Section IV administration of concentrated potassium chloride. 3.4 The NPSA have issued an Information resource to support the reporting of SIs which is included as Appendix 2. This lists a range of incidents that must be reported as SIs. However, the list is not exhaustive and if Providers require advice or guidance they should seek further clarification from the Quality and Patient Safety team at NHSW on / or the Patient Safety Action Team at the SHA on REPORTING & MANAGING SERIOUS INCIDENTS (SIs) 4.1 Who should report SIs? All Providers are required to report every SI occurring within their service. 4.2 How are SIs reported? NHSW Serious Incidents (SIs) reporting policy and procedure Page 6 of 24

7 4.2.1 All SIs must be reported using the UNIFY system, previously known as Strategic Executive Information System (STEIS), to the SHA Worcestershire Acute Hospitals Trust (WAHT), Worcestershire PCT (WPCT) and Worcestershire Mental Health Partnership Trust (WMHPT) must report the incident directly to the SHA using the UNIFY system and inform NHSW at the time of reporting All other Providers must report the incident directly to NHSW Quality and Patient Safety Team using the SI Reporting Template (Appendix 3). NHSW will then report this to the SHA using the UNIFY system UNIFY is the source of Performance Management information for the Department of Health and the NHS. It brings together the data collection and performance reports for the NHS and Social Care System in England. The UNIFY system allows users to report and view (depending on access rights) Serious Incidents previously known as Serious Untoward Incidents. 4.3 What information is required for each SI? Full details of the incident are required when reporting the SI, including when and what happened; who was involved (all person identifiable information must be anonymised); information about how the incident is being managed, including media handling arrangements, if appropriate; any immediate actions implemented to prevent reoccurrence. 4.4 When should a SI be reported? SIs should be reported as soon as the incident becomes known to the provider organisation (via UNIFY or direct to NHSW, as applicable) and within a maximum of two working days. If there is a delay between the incident occurring and it being reported an explanation of the delay should be included with the report Limited information early is better than full information late in order to ensure there are no surprises. This should be followed up with full/additional information at the earliest opportunity Where the incident is of particular gravity it should be reported immediately to NHSW by telephone to the Quality and Patient Safety Team ( / If immediate SI notification is required out of hours please contact the on-call manager for NHSW via the switchboard on or He/she will be responsible for initiating any further call out/reporting procedure; (Appendix 4) 4.5 Lead Reporting Organisation If more than one organisation is involved in a SI, the organisation which has discovered the incident should make the initial SI report as applicable, NHSW Serious Incidents (SIs) reporting policy and procedure Page 7 of 24

8 having first made contact with the other involved organisations to confirm that they are making the report The organisations involved must agree on who will take the lead role in investigating the SI and updating of UNIFY. The reporting organisation must notify the SHA and NHSW of the incident via UNIFY and the decision of which organisation is taking the lead, if not the reporter via . For providers without direct access to UNIFY this reporting should be done through NHSW. 4.6 Reporting of SIs to the CQC Provider organisations must, as part of the new registration requirements arising from the Health and Social Care Act 2008, notify the CQC about events that indicate or may indicate risks to ongoing compliance with registration requirements, or that lead or may lead to changes in the details about the organisation on the CQC s register. Reports about serious incidents are defined in the CQC s guidance, Essential Standards of Quality and Safety. Most of these requirements are met by reporting via UNIFY which is then passed to the NPSA, and the NPSA will forward relevant information to the CQC However, organisations subject to special measures must notify the Care Quality Commission directly of any SIs in addition to the routine reporting procedures included within this policy. 4.7 Grading of a SI Serious Incident grading (Appendix 1) is a component of the national framework which may be new for many organisations. Its purpose is to help reduce under reporting of serious incidents by encouraging early reporting of all possible serious incidents. The grading should initially be carried out by the Provider Once a reported incident has been graded by the Provider the SHA/NHSW will review the grading of the seriousness of the incident for the purposes of determining the investigation and monitoring approach. 4.8 Investigation of SIs by Providers Following notification and declaration of an SI, an internal investigation must be promptly established by the Provider. This should be conducted using Root Cause Analysis (RCA) techniques and in accordance with other best practice guidance issued by the NPSA All Providers should ensure that whilst undertaking their investigation there is no discrimination on the grounds of gender, age, disability, race, religion, sexuality or social class Where court proceedings in relation to the incident have started, or are likely, legal advice should be sought by the Trust with a view to ensuring that NHSW Serious Incidents (SIs) reporting policy and procedure Page 8 of 24

9 the investigation does not prejudice those proceedings. The Memorandum of Understanding between the Police, the HSE and the NHS should be followed. 4.9 Updating the SI report The UNIFY record must be updated when the situation changes and this may include the following scenarios: If the situation deteriorates If the level of media interest changes (especially if it increases) As the 'line to take' changes When the situation is resolved Police interest Increased level of family concern High profile coroner s inquest Court case Publication of an Inquiry/Investigation report Outcome, within one working day, of a serious case review panel meeting Outcome of third party review e.g. POVA panel, Ofsted judgment for child protection Serious case review These and similar events, could happen several weeks or months after the original incident. It is important that NHSW and the SHA are ready to deal effectively with any resulting media and public interest and therefore regular and appropriate updating of the SI record on UNIFY is imperative Providers without access to UNIFY must advise NHSW of any changes in the situation. NHSW will ensure the UNIFY system is updated accordingly Timescales for investigation and reporting the findings from the investigation The timescales for completing the investigation and reporting the findings are included in the Grading and Timescales for Investigation Flow Chart (Appendix 5) The completed RCA/investigation report and action plan must be submitted to NHSW in line with contract requirements NHSW expects SI reports to be based on the NPSA Level 2 investigation template. Templates and guidance are available on the NPSA website: As a minimum the report should include the following: Incident date Incident description Actual effect on patient/service NHSW Serious Incidents (SIs) reporting policy and procedure Page 9 of 24

10 Involvement and support of patients and relatives Clear, fact based, chronology of events leading up to the incident Care and Service Delivery problems Contributory Factors Root Causes Recommendations Action Plan Sign off by the Clinical Governance team/risk Committee All reports must contain anonymised information. The names of any practitioners or staff involved must not be included on the UNIFY report or the final SI report. Staff should be referred to by their job title. Other individuals should be referred to by initials only The UNIFY system must be updated to record the summary from the RCA and the lessons learnt from the SI. This should be done either directly via UNIFY or via NHSW Depending on the severity of the SI, and in all cases of Never Events, NHSW will require more frequent interim updates on progress and findings of the investigation. The frequency of these will be determined on an individual case basis Extension of timescales Providers need to advise NHSW of any anticipated delays to the completion of the investigation and submission of the investigation report Closure of SIs The SHA will close the UNIFY record once it is satisfied that the RCA has addressed the issues to minimise the risk of reoccurrence. 5.0 REASONS FOR NHSW CONTACTING A PROVIDER ORGANISATION Evidence of the following will result in the Provider being contacted by NHSW; The following list is not exhaustive: 5.1 Evidence of under reporting of SIs. 5.2 An incident that only comes to light via another organisation, Trust or media when it was known to the Provider for some time 5.3 Time lag in reporting not explained by the circumstances of the incident. 5.4 NHSW acknowledges that some SIs may only become apparent some time after the event or after the Provider has completed an investigation of a lesser event which deems it to now be a SI and NHSW will accept reasonable justifications in such instances NHSW Serious Incidents (SIs) reporting policy and procedure Page 10 of 24

11 5.5 Thresholds for reporting: There is evidence that Providers have a high threshold for reporting SIs and are not reporting all types of SIs (e.g. not reporting C Diff/MRSA deaths on part 1 of the death certificate). 5.6 Quality of reporting/reports: UNIFY records, RCA and action plans that are submitted to NHSW that fail to meet the minimum standard of 100% compliance will result in the Q&PST discussing improvement required with the respective Provider. 5.7 Trends in clinical issues/common themes: If NHSW feels that common themes or trends in either clinical or non clinical issues are not being reported this will be followed up. 6.0 DUTIES/RESPONSIBILITIES 6.1 NHS Worcestershire Chief Executive The Chief Executive is accountable and responsible to the Board for ensuring that resources, policies and procedures are in place to ensure the effective reporting, recording, investigation and treatment of incidents. In practice the Chief Executive may delegate the day-to-day responsibility for this duty to Heads of Department and Directorates The Trust Board The Trust Board has overall responsibility for ensuring that an appropriate incident reporting system is in place for the reporting of incidents and monitoring of incident trends, including SIs, including the recording of all Never Events in the annual reporting arrangements The Quality and Patient Safety Assurance Team The Quality and Patient Safety Team has a responsibility to: Oversee the management of all SIs that occurs within NHSW, ensuring they are reported and investigated in accordance with this policy Ensure robust systems are in place for receiving notification of all SIs, including Never Events, within commissioned services Monitor the number and types of SIs reported and to identify any patterns or trends so that learning can take place across the Worcestershire Health Economy Monitor the outcomes and action plan implementation from SI Root Cause Analysis (RCA) investigations. NHSW Serious Incidents (SIs) reporting policy and procedure Page 11 of 24

12 Ensure that the correct people are informed of SIs promptly so there are no surprises and to ensure the briefing of concerned organisations on potential media interest Commission independent investigations if there is a statutory requirement to do so and this is not being arranged by the SHA Monitor the quality of information regarding SIs based on minimum requirements. This will inform future policy and learning as well as individual organisational feedback For all SIs reported by a provider where the individual affected is not the responsibility of NHSW, the relevant home commissioner must be advised and kept updated on the investigation Report Never Events (National Patient Safety Agency, 2010), and to take action and monitor. It is the SHA s responsibility to ensure the PCT provides adequate assurance to minimise future risk and prevent reoccurrence In managing SIs NHSW must: Familiarise itself with the details of the incident and ensure that the situation is being managed by a senior/appropriate member of staff from the provider Liaise with the Provider about immediate actions necessary to safeguard patients and prevent a reoccurrence Ensure any necessary media management is proportionate and well managed. Gain assurance from providers of their processes for managing SIs, monthly monitoring of RCAs and implementation of subsequent action plan for each SI. Review of trends/clusters to identify hot spots with updates on action plans and subsequent learning NHSW will submit a brief quarterly report to the SHA to cover: Number of SIs opened and closed during that quarter across the health economy Timeliness and quality of SI investigation reports and learning and action in response to SIs Themes and trends How the PCT has used the SI intelligence in its overall performance management of providers and commissioning arrangements Communications/relationships between NHSW and its providers and the SHA Learning leading to quality improvement Any other relevant business. NHSW Serious Incidents (SIs) reporting policy and procedure Page 12 of 24

13 6.2 West Midlands Strategic Health Authority (SHA) West Midlands Strategic Health Authority acts as a focal point for the health community where information about SIs within the region can be recorded, monitored, analysed and learning disseminated. The SHA provides objective advice on a range of issues. However, the SHA also needs current information to facilitate Ministerial and Senior Civil Servant briefings and to manage the media appropriately The SHA is responsible for: Performance management of PCTs Serious Incident management systems and processes Updating, maintaining and analysis of the Patient Safety Dashboard, which provides statistical and qualitative intelligence data to assist the wider quality assurance framework Working in partnership with PCTs on particular SIs where the scale /severity of the incident exceed the PCT s boundaries and/or capacity Commissioning independent investigations and inquiries in cases which meet the following nationally agreed criteria: When a homicide has been committed by a person who is or has been, under care which is subject to the regular or enhanced care programme approach, and/or of specialist mental health services in the six months prior to the event. When it is necessary to comply with the State obligation under Article 2 of the European Convention on Human Rights. Whenever an agent of the State is, or may be, responsible for a death or where the victim sustains life threatening injuries, there is an obligation on the State to carry out an effective investigation. This means that the investigation should be independent, reasonably prompt, provide a sufficient element of public scrutiny and involve the next of kin to an appropriate extent The SHA will ensure that SIs are properly investigated, actions are being taken to improve patient safety and that lessons are learnt in order to minimise the risk of similar incidents occurring in the future. 6.3 Responsibilities of all providers: All Trusts/PCTs are expected to have the following systems and processes in place and be able to demonstrate this to NHSW as the coordinating commissioner as requested. All other providers must have similar systems and processes in place which address the requirements below and NHSW Serious Incidents (SIs) reporting policy and procedure Page 13 of 24

14 which allow for the robust identification, reporting, investigation and monitoring of SIs. Identified Board lead for patient safety and designated deputy Arrangements for clinical governance to provide assurance of the quality of clinical care and patient safety A local policy for incident reporting and management that clearly sets out how serious incidents will be identified and reported by staff and managed within the organisation A system to ensure robust Information Governance and Transfer of Data A mechanism and database for recording all SIs Systems in place to ensure the Board is aware of all SIs including trends, management and monitoring of action plans, and evidence of changes brought about to improve patient safety (this may include changes to practice, education and training) Arrangements in place to ensure the principles of Being open - communicating patient safety incidents with patients and their carers, (National Patient Safety Agency, 2009) are applied. Arrangements in place to support and safeguard any victims and their families and ensure patients, relatives and concerned parties are kept informed of ongoing events in relation to the SI, including where appropriate the involvement of the media Mechanisms to ensure appropriate action is taken and referrals are made as necessary using the cause for concern process for the professional regulatory bodies, as appropriate Arrangements for ensuring that investigations take place as appropriate, action plans are devised and recommendations implemented Arrangements in place for ensuring staff receive support following SIs Systems in place for ensuring that frontline staff receive feedback from serious incidents Comprehensive records of investigation reports including a list of all contacts made and offers of support to victims and their families if relevant Arrangements in place to ensure that relevant staff receive training and development in relation to patient safety and root cause analysis A process in place for the management of Serious Case Reviews Systems in place to identify trends in near misses and where those trends constitute a significant risk, escalation to a SI report 7.0 MONITORING The policy will be monitored in the following way: NHSW Serious Incidents (SIs) reporting policy and procedure Page 14 of 24

15 7.1 The Q&PST will provide bi-monthly reports to the Quality & Patient Safety Assurance Committee (Q&PSAC), to assure them that all SIs reported to NHSW are thoroughly investigated by the respective Providers according to best practice and that actions are taken to improve clinical quality and patient safety. 7.2 The Quality and Patient Safety Team (Q&PST) will monitor the SIs reported for trends. 8.0 DISSEMINATION, IMPLEMENTATION AND ACCESS TO THIS DOCUMENT This policy will be accessible via the NHSW website. The principles embedded within the policy will be included in Induction training for staff and in Minimising Risk in your Working Environment. NHSW will ensure that relevant staff receives training in relation to RCA. 9.0 REVIEWING, UPDATING AND ARCHIVING OF THIS DOCUMENT The Quality & Patient Safety Team will review this policy three years from publication, unless circumstances arise requiring an early review or updating of this policy. NHSW Serious Incidents (SIs) reporting policy and procedure Page 15 of 24

16 10.0 REFERENCES Care Quality Commission (2009). Essential Standards of Quality and Safety. Data Protection Act 1998 Department of Health 1998: A First Class Service Quality in the new NHS. Department of Health 2000: An organisation with a memory Report of an expert group on learning from adverse events in the NHS chaired by the Chief Medical Officer: Department of Health 2001: Building a Safer NHS for Patients. Department of Health 2001: Doing Less Harm Improving the safety and quality of care through reporting, analysing and learning from adverse incidents involving NHS patients Key requirements for health care Providers. Department of Health (2010) Checklist for reporting, managing and investigating Information Governance Serious Untoward Incidents. Freedom of Information Act Memorandum of understanding: Investigating patient safety incidents involving unexpected death or serious untoward harm. A protocol for liaison and effective communications between the National Health Service, Association of Chief Police Officers and Health and Safety Executive. Feb 2006: NHS West Midlands (2010): Serious Incidents (SI). Reporting Policy and Procedure. The National Patient Safety Agency (2004): Seven Steps to Patient Safety. Your guide to safer patient care. National Patient Safety Agency (2009). Data Quality Standards. Guidance for organisations reporting to the reporting and learning system. The National Patient Safety Agency. 2010: National Framework for Reporting and Learning from Serious Incidents Requiring Investigation. National Screening Committee, NHS Cancer Screening Programmes (2010). Managing Serious Incidents in National Screening Programmes. NHSW Serious Incidents (SIs) reporting policy and procedure Page 16 of 24

17 11.0 GLOSSARY CQC DH NHSW NPSA NRLS POVA Provider Ofsted Q&PST Q&PSAC RCA SHA SI UNIFY WAHT WMHPT WPCT Care Quality Commission Department of Health NHS Worcestershire National Patient Safety Agency National Reporting and Learning System Protection of Vulnerable Adults NHS funded healthcare including main NHS providers, independent contractors (GPs, Dentists, Optometrists and Pharmacist), Nursing homes, private providers delivering NHS funded healthcare in Worcestershire. The Office for Standards in Education, Children s services and Skills Quality & Patient Safety Team NHSW Quality & Patient Safety Assurance Committee NHSW Root Cause Analysis - A retrospective review of a safety incident undertaken in order to identify what, how, and why it happened. The analysis is then used to identify areas for change, recommendations and sustainable solutions, to help minimise the re-occurrence of the incident type in the future Strategic Health Authority Serious Incident Department of Health Information Gathering System Worcestershire Acute Hospital Trust Worcestershire Mental Health Partnership Trust. Worcestershire Primary Care Trust NHSW Serious Incidents (SIs) reporting policy and procedure Page 17 of 24

18 Appendix 1 Grading of serious incidents NHSW Serious Incidents (SIs) reporting policy and procedure Page 18 of 24

19 Appendix 2: NPSA Information resource to support the reporting of SIs Separate file attached NHSW Serious Incidents (SIs) reporting policy and procedure Page 19 of 24

20 Appendix 3: Serious Incident (SI) Reporting Template Date of the incident: Time of the incident: The site and location that the incident occurred: The type of person affected by the incident: Example: Community patient; GP patient; In-patient; Ambulance; Out-patient; Other The affected persons date of birth: The affected person s gender: The affected person s ethnicity (if known): The affected person s employer (if agency staff or locum): The affected person s home PCT ie Registered with a Worcestershire GP or from out of area in which case specify where The speciality in which the affected person was being treated/working/visiting: Was the incident a Near Miss or an actual SI: A brief description of what happened: A brief description of the containment/immediate action taken The type of incident that occurred and grade: See Appendices 1 & 2 The likelihood of recurrence of the incident: Almost certain; Likely; Possible; Unlikely; Rare Is the incident reportable? To whom? Example: Coroner; Police; NPSA; HPA NHSW Serious Incidents (SIs) reporting policy and procedure Page 20 of 24

21 Will the incident attract media interest? If yes, nature of interest and what action is being taken by provider Apparent outcome of the incident: Most likely consequences of the incident: Potential risk to other patients: The reporting provider internal incident number (if applicable): The name and designation of the person reporting the incident, to include contact details: This information is required in the event that NHSW require further information/ clarification Name: Designation: Contact Details: The name and designation of the person investigating the incident, to include contact details: Name: Designation: Contact Details: Instructions for use of this template: 1. Click with your mouse onto the grey box in each section 2. Begin typing 3. If you want to put a blank line between text, hit the return key 4. If you want to indent your typing press and hold the Ctrl key before hitting the tab key 5. If you hit the tab key by mistake it will add a new blank row to that section: either press the undo key or highlight the row and choose delete row from your Table functions NHSW Serious Incidents (SIs) reporting policy and procedure Page 21 of 24

22 APPENDIX 4 ESSENTIAL CONTACT DETAILS NHSW Contact details Telephone numbers Karen Hunter Internal Head of Quality and Patient Safety External NHS Karen.hunter2@nhs.net Annie Coyle Internal Quality & Patient Safety Assurance External Co-ordinator NHS dcoyle@nhs.net Out of Hours via switch board for on call Manager: Alexandra Hospital WRH External Stakeholders: Strategic Health Authority (SHA) Health & Safety Executive National Patient safety Agency NHS Litigation Authority NHSW Serious Incidents (SIs) reporting policy and procedure Page 22 of 24

23 Appendix 5- Grading and Timescales for Investigation Flow-Chart: National Framework for Reporting and Learning from Serious Incidents NHSW Serious Incidents (SIs) reporting policy and procedure Page 23 of 24

24 Appendix 6 Equality Impact Assessment Report Template Name of policy or function: Serious Incidents (SIs) Reporting Policy and Procedure Responsible Manager: Annie Coyle Date EIA completed: 14 th September 2010 Description of aims of function/policy: To explain the processes in place to ensure that NHSW is informed of all SIs within the services it commissions, irrespective of the Provider. To increase the robustness of SI reporting by all Providers. To clarify reporting lines to help strengthen the conduct, management and handling of investigations following an SI that occurs within NHSW. To clarify roles and responsibilities in respect of SIs for all staff providing NHS-funded care. Brief summary of research and relevant data: See References in Item 10 of policy. Methods and outcomes of consultation: See Circulation List for Policy. Policy will be ratified by the Quality and Patient Safety Assessment Committee Results of Initial Screening or Full Equality Impact Assessment: Initial or Full Equality Impact Assessment? Equality Group Race Gender Disability Age Sexual Orientation Religion or Belief Human Rights Initial Assessment of Impact No adverse effect No adverse effect No adverse effect No adverse effect No adverse effect No adverse effect No adverse effect Decisions and or recommendations (including supporting rationale): No further action required Equality action plan (if required): N/A Monitoring and review arrangements (include date of next full review): At review of the policy, 3 years from ratification Department Directorate Director Report produced by and job title Quality and Patient Safety Clinical Development Sandra Brennan Annie Coyle, Quality and Patient Safety Co-ordinator Date report produced 14 th September 2010 Date report published November 2010 NHSW Serious Incidents (SIs) reporting policy and procedure Page 24 of 24