Management of Incidents Policy

Transcription

1 Management f Incidents Plicy Dcument Reference Dcument Status POL015 Versin: V6.0 Apprved DOCUMENT CHANGE HISTORY Initiated by Date Authr (s) Serius Incident June 2009 Risk Manager Panel Versin Date Cmments (i.e. viewed, r reviewed, amended apprved by persn r cmmittee) V2.0 September 2009 Apprved at Trust Bard V2.1 March 2011 Reviewed by Implementatin Manager and Claims and Litigatin Manager fr NHSLA cmpliance V2.1 July 2011 Apprved by Risk Management Grup V3.0 August 2011 Apprved by Executive Management Team V3.1 January 2015 Risk Manager V3.1 February 2015 Apprved by Clinical Quality and Safety Grup V4.0 June 2015 Apprved by ELB V5.0 February 2015 Minr amendments apprved by ELB V5.1 June 2017 Amended and reviewed by Clinical Quality and Safety Grup V6.0 September 2017 Apprval at SLB and ELB EEAST, POL015 - Management f Incidents Plicy, V6.0 Page 1 f 21

2 Dcument Reference Recmmended at Date Apprved at Date Review date f apprved dcument Equality Analysis January 2015 Linked prcedural dcuments Disseminatin requirements Part f Trust s publicatin scheme Health and Scial Care Act 2008 (Regulated Activities) Regulatins 2010; Regulatin 19. Directrate: Nursing and Clinical Quality Clinical Quality and Safety Grup June 2017 Executive Leadership Bard June 2017 March 2019 Duty f Candur (frmerly Being Open) Plicy Claims Plicy Cmplaints Plicy Investigatin Guidance Whistle-blwing Plicy Risk Management Strategy Serius Incident Plicy All managers and staff, via and intranet Yes The East f England Ambulance Service NHS Trust has made every effrt t ensure this plicy des nt have the effect f unlawful discriminatin n the grunds f the prtected characteristics f: age, disability, gender reassignment, race, religin/belief, gender, sexual rientatin, marriage/civil partnership, pregnancy/maternity. The Trust will nt tlerate unfair discriminatin n the basis f spent criminal cnvictins, Trade Unin membership r nn-membership. In additin, the Trust will have due regard t advancing equality f pprtunity between peple frm different grups and fster gd relatins between peple frm different grups. This plicy applies t all individuals wrking at all levels and grades fr the Trust, including senir managers, fficers, directrs, nn-executive directrs, emplyees (whether permanent, fixed-term r temprary), cnsultants, gvernrs, cntractrs, trainees, secnded staff, hmewrkers, casual wrkers and agency staff, vlunteers, interns, agents, spnsrs, r any ther persn assciated with the Trust. All Trust plicies can be prvided in alternative frmats. EEAST, POL015 - Management f Incidents Plicy, V6.0 Page 2 f 21

3 Cntents Page 1. Intrductin 4 2. Purpse 4 3. Duties The Bard Quality Gvernance Cmmittee Clinical Quality and Safety Grup Chief Executive Officer Directr f Nursing and Clinical Quality SI Learning Grup Patient Safety Team Senir Lcality Managers/Heads f Department Investigating Officer (IO) Staff and ther wrkers Trust specialists 6 4. Definitins 6 5. Incident reprting and management prcess Incident reprting and management flwchart Incident Reprting External ntificatin f Patient Safety Incidents Incidents relating t external rganisatins Incident scring and apprpriate levels f investigatins Duty f Candur Outcmes and identificatin f learning Feedback t staff Quality assurance 12 6 Equality Impact Assessment 12 7 Prcess fr Mnitring Cmpliance and Effectiveness 12 8 Standards/Key Perfrmance Indicatrs References 12 Appendix A Example Incidents and Near Misses 14 Appendix B Risk Matrix 15 Appendix C Investigatin Templates 19 Appendix D Equality Impact Assessment 22 EEAST, POL015 - Management f Incidents Plicy, V6.0 Page 3 f 21

4 1. Intrductin It is recgnised that within a healthcare rganisatin, incidents and near misses can and d ccur. Recgnitin and reprting f incidents and near misses is vital t the way in which the Trust can respnd t issues and avid repetitin f avidable incidents. Thrugh effective incident reprting, investigatin and review, the East f England Ambulance Service NHS Trust aims t learn, change and develp prcesses, prcedures and strategies, in rder t reduce the level f risk within the rganisatin. The aim f this plicy is t encurage incident reprting, ensure rbust investigatins and learn frm incidents and near misses, in rder t maintain a high standard f care t patients, as well as t reduce the risk f lss, damage r injury t patients, staff and thers, prtecting the Trust s assets. 2. Purpse This plicy has been updated in line with the Trust s Patient Safety Strategy. The purpse f this plicy is t make clear the Incident reprting and investigatin prcess, frm incident recgnitin thrugh t cmpletin f the actins and clsure. If the plicy is implemented successfully, the result will be: Cntinuus reductin in levels f avidable harm The prvisin f a safe envirnment fr staff, patients, visitrs and cntractrs All incidents and near misses reprted and investigated in a timely manner and apprpriate learning and actins taken as a result Successful implementatin f this plicy has the verarching aim f reducing patient harm and imprving safety fr patients, staff and ther key stakehlders. 3. Duties 3.1 The Trust Bard The Trust Bard will receive infrmatin n Incidents via the Quality Reprt. This is in rder t seek assurance that internal cntrls are in place and are perating effectively in relatin t incident management and safety imprvement. 3.2 Quality Gvernance Cmmittee The Cmmittee is directly accuntable t the Bard and seeks t prvide assurance relating t systems and prcedures cncerning patient safety. The Cmmittee will receive reprts relating t incident management and issues highlighted thrugh investigatins in rder t prvide assurance t the Bard, r t raise cncerns. 3.3 Clinical Quality and Safety Grup (CQSG) The CQSG is directly accuntable t the Executive Leadership Team and has decisin-making pwers devlved frm the Bard. Its purpse is t prmte the delivery f safe, effective patient care utcmes and ensure patient and carers views are actively sught, cnsidered and acted upn and t ensure that apprpriate mechanisms are in place t deliver high quality care. The CQSG will receive reprts n incidents including trends, themes, issues t nte, and lessns learned where apprpriate. EEAST, POL015 - Management f Incidents Plicy, V6.0 Page 4 f 21

5 3.4 Chief Executive Officer The Chief Executive, as Accuntable Officer, has verall respnsibility n behalf f the Trust Bard fr risk management, including the management f Incidents. 3.5 Directr f Nursing and Clinical Quality The Directr f Nursing and Clinical Quality is respnsible fr verseeing the arrangements fr Clinical Gvernance. This will prvide assurance f the quality f clinical care and patient safety. The Directr is the designated Bard member respnsible fr cmpliance with the incident reprting prcedures n behalf f the Bard and Chief Executive. 3.6 SI Learning Grup The SI Learning Grup is respnsible fr the mnitring f trends and themes in relatin t aggregated infrmatin frm cmplaints, cncerns, litigatin, incidents, Serius Incidents and any ther frms f patient experience data, with required actins t be taken. The Grup is respnsible fr mnitring cmpletin f the actins and reductin in the trends and issues seen as a result. 3.7 Patient Safety Team The Patient Safety Team is respnsible fr the mnitring f incidents and near misses reprted and fr escalating ptential Serius Incidents (see Serius Incident Plicy). The Patient Safety Team acts t prvide a quality assurance mechanism in relatin t investigatins undertaken. They are als respnsible fr identifying trends and themes and reprting these t the apprpriate managers and grups/cmmittees fr actin. The Patient Safety Team acts as advisrs t managers when assistance r supprt is required. 3.8 Senir Lcality Managers/Heads f Department Senir Lcality Managers are respnsible fr the prvisin f care within their allcated lcality. They are respnsible fr ensuring that an investigatin int any incident is cnducted in a timely manner and t a high standard, in rder t ensure that actins are taken t prevent a recurrence. The wnership f an incident r near miss sits with the Senir Lcality Manager, r relevant equivalent. These Managers are respnsible fr verseeing the investigatin prcess and t prvide guidance and supprt t any manager they may have delegated the investigatin t. The Senir Lcality Manager r equivalent in which the incident ccurred is respnsible fr assigning an apprpriate Investigating Officer and ensuring sufficient time fr the investigatin is allcated. They are respnsible fr ensuring that the investigatin fllws due prcess and that the cnclusins drawn are sund and accurate. They are als respnsible fr ensuring learning is disseminated and shared. The Senir Lcality Manager is als respnsibility fr implementing Duty f Candur discussins with patients and their families, supprting the Investigating Officer. 3.9 Investigating Officer (IO) The Investigating Officer is respnsible fr ensuring that the investigatin is in cnjunctin with this plicy and that the prcess is undertaken efficiently and effectively using rt cause analysis methdlgy and is prprtinate t the incident. The IO must prduce a reprt thrugh the cmpletin f the investigate this incident sectin f the incident reprt n Datix, which addresses every area f the incident and als identify any areas where remedial actin may be taken. EEAST, POL015 - Management f Incidents Plicy, V6.0 Page 5 f 21

6 Thrughut the investigatin the IO will maintain regular cntact and prvide feedback t staff invlved in the incident and t ensure apprpriate supprt is made available where apprpriate. Where apprpriate, the Investigatin Officer shuld make and maintain cntact with the patient/family t ensure a recrd f any meeting(s) r infrmatin shared is dcumented and enclsed with the final reprt (as per Duty f Candur plicy) Staff and Other Wrkers All staff emplyed by EEAST share the respnsibility f reprting any incident r near miss Staff r wrkers shuld reprt any such cncerns via the Datix system as sn as pssible and withut delay. If staff are cncerned in relatin t a pssible Serius Incident, this shuld als be identified t the manager n duty n that shift, r via the Emergency Operatins Centre. Supprting dcumentatin shuld als be passed n withut delay. Staff invlved in an incident r near miss are required t fully participate in an investigatin penly and hnestly, in rder t assist with establishing the facts and the reasns fr the incident, and t identify ways in which this lessns can be learned t avid recurrence Trust Specialists Specialist staff such as Safeguarding, Infectins, Preventin and Cntrl, Health and Safety and Risk are respnsible fr mnitring issues arising within their specialist field. They are nt respnsible fr rutinely cnducting incident investigatins; hwever shuld make themselves available t prvide advice and supprt t managers and investigatrs where there are specialist cnsideratins t take. 4. Definitins Adverse Incident An incident can be defined as smething unexpected that has happened, which resulted in patient r purchaser dissatisfactin, injury t a patient, visitr r member f staff r lss r harm t the Trust r its prperty. Clinical adverse incidents are events r circumstances arising during NHS care that culd have, r did, lead t unintended r unexpected harm, lss r damage. Sme examples f incidents that wuld need t be reprted n the Datix system include: Patient became aggressive twards crew. Patient given incrrect dsage f medicatin. Staff member pulled muscle whilst lifting a patient. Patient infrmatin lst/misplaced. Equipment malfunctins whilst being used t treat a patient. Near Miss An incident that has the ptential t cause harm but careful management has prevented the incident. Fr example, slippery flr where n signs have been laid ut but reslved prir t a slip; delay in ambulance but deteriratin prevented by transprting by Rapid Respnse Vehicle. Serius Incident Requiring Investigatin A serius incident requiring investigatin is defined as an incident that ccurred in relatin t an NHS funded service and care resulting in ne r mre f the fllwing: Unexpected r avidable death f ne r mre patients, staff, visitrs r members f the public; Serius harm t ne r mre patients, staff, visitrs r members f the public r where the utcme requires life-saving interventin, majr surgical/medical interventin, EEAST, POL015 - Management f Incidents Plicy, V6.0 Page 6 f 21

7 permanent harm r will shrten life expectancy r result in prlnged pain r psychlgical harm (fr a cntinuus perid f 28 days); A scenari that prevents r threatens t prevent a prvider rganisatin s ability t cntinue t deliver healthcare services, fr example, actual r ptential lss f persnal/rganisatinal infrmatin, damage t prperty, reputatin r the envirnment, r IT failure; Allegatins f abuse; Adverse media cverage r public cncern abut the rganisatin r the wider NHS; One f the cre set f Never Events as updated n an annual basis Data lss and serius breaches f cnfidentiality 5. Incident Reprting and Management Prcess 5.1 Incident Reprting and Management Flwchart Key timeframes within the incident management prcess and wh is respnsible: 1. Any incident r near miss shuld be reprted within 24 hurs f it being identified (staff member respnsible) and verbally t their line manager in rder t identify whether immediate actin needs t be taken 2. An Investigating Officer shuld be assigned within the incident being reprted n Datix (Senir Lcality Manager r equivalent) within five days f the incident being reprted 3. Duty f Candur t be discharged within 10 days f the incident being reprted (Senir Lcality Manager r equivalent with the Investigating Officer) 4. Investigatin cmpleted within 35 days f the incident being reprted (Investigating Officer) 5. The investigatin reviewed and finally apprved within 5 days f investigatin cmpletin (Senir Lcality Manager r equivalent) The fllwing flw chart demnstrates the steps within the incident management prcess and sets ut the timescales fr each cmpnent: EEAST, POL015 - Management f Incidents Plicy, V6.0 Page 7 f 21

8 5.2 Incident Reprting Staff are respnsible fr reprting every incident r near miss that they are aware f. In the instance f tw r mre staff being witness/invlved in an incident, it shuld nly be reprted nce and therefre the staff invlved must determine wh will reprt it. An incident r near miss must be reprted via the Datix incident reprting system. There are three ways: 1. Via the Datix web page n the Trust intranet: 2. Via the 24/7 Single Pint f Cntact telephne line Via the link n the Tughbk If there is a need t take significant actin t manage the incident immediately, staff shuld escalate their cncern t the manager n Duty at the time, in additin t reprting the incident n Datix. In rder fr a rbust and thrugh investigatin t ccur, the standard f the incident reprt submissin is vital. Key aspects that must be included: Accurate incident date and time Accurate lcatin f where the incident ccurred Incident number (CAD event, cleric r Adastra number) if applicable Accurate details f the peple invlved (in the persns affected sectin) A detailed and factual accunt f what has happened, and what utcme the reprter wuld like t see. Whether any harm has ccurred must be clearly stated and if s, what it was Fr examples f incidents and near misses, please see Appendix A. 5.3 External ntificatin f Patient Safety Incidents The Trust has a duty t reprt all patient safety incidents externally t the Natinal Patient Safety Agency, via the Natinal Reprting and Learning System (NRLS). This is t assist with natinal learning and actin via the Safety Alerting system (CAS). The fllwing incidents shuld be reprted thrugh the NRLS: Patient injury (fall, skin tear, etc.) Medicatin errrs (verdse, incrrect medicatin, ut f date drugs, inability t administer, adverse reactins etc.) Inability t deliver treatment (equipment errrs, lack f equipment) Clinical errrs/inapprpriate treatment/misdiagnsis Deteriratin in cnditin thrugh delays etc. Persnal/sensitive infrmatin lss This list is nt exhaustive and ther incident types shuld be cnsidered n a case by case basis. The Patient Safety Team is respnsible fr grading and reprting patient safety incidents t the NRLS. This shuld be undertaken at least mnthly, but ideally weekly. Prir t uplad, NRLS reprtable incidents shuld be reviewed by either the Risk Manager r Head f Quality Gvernance t ensure cnsistency in the grading and reprting apprach. Incidents are upladed via Incidents relating t external rganisatins Due t the nature f the wrk the Trust undertakes, staff have ccasin t reprt incidents and near misses relating t ther prvider rganisatins, including hspitals, care hmes and care agencies. These incidents are reprted n the Trust s incident reprting system (Datix) in the same way as an internal incident. As these incidents relate t anther rganisatin, it is nt pssible r apprpriate fr the East f England ambulance service t cnduct the investigatin. Our respnsibility is t ntify the prvider EEAST, POL015 - Management f Incidents Plicy, V6.0 Page 8 f 21

9 rganisatin f the details f the incident and t share the necessary details t enable them t cnduct their wn investigatin. This can be dne in a number f ways: (via nhs.net accunt) t the relevant department at the prvider rganisatin Telephne t the prvider rganisatin s PALS department (dcument in the incident reprt n Datix) Via external rganisatin ntificatin letter (template n Datix) Once this has been passed t the relevant rganisatin, it is apprpriate t clse this incident reprt, prviding feedback t the reprter that it has been passed t the crrect rganisatin fr internal investigatin. If feedback is received frm the ther rganisatin, this shuld be attached t the Datix and shared with the staff member. Incidents relating t external rganisatins will be cmpleted by the Patient Safety Team 5.5 Incident Scring and apprpriate levels f investigatins The level f investigatin and analysis required fr each incident r near miss shuld be assessed thrugh the risk matrix and nt slely n the actual cnsequences f the incident. Fr example, a near miss n ne ccasin culd becme a fatality in the future if the ptential risk is nt identified and investigated thrughly. The risk matrix is fund n the Investigate this Incident page f the incident n Datix and shuld be cmpleted by the Investigating Officer. It shuld be nted hwever that this may be cmpleted by the Senir Lcality Manager (r equivalent) r the Patient Safety Team in the instance f a ptential Serius Incident. The table is as fllws, but see appendix B fr mre detail: If the risk is high (red r amber), it is imprtant that the cntributry factrs and rt causes are investigated and addressed and therefre an in-depth investigatin shuld ccur and be dcumented within the Datix system. The purpse f an investigatin is t establish what happened and identify the rt cause s that steps can be put in place t prevent a recurrence. T investigate incidents and near misses, the Trust uses Rt Cause Analysis methdlgy and investigatin tls in rder t systematically review what ccurred and identify the underlying causes. Investigatins shuld generally always include: Ensure all immediate remedial actins have been taken (injuries treated, scene preserved, defective equipment islated etc.) Ensure relevant individuals have been fully infrmed f the incident Identify peple t be interviewed and dcument interviews and statements etc. Invlve internal specialists as required Review any necessary physical evidence (patient care recrd, equipment, training recrds, plicies and prcedures etc.) Identify all rt causes and cntributry factrs which led t the incident Identify what learning and actin is required t prevent a recurrence Useful tls fr carrying ut an investigatin include (appendix C fr templates): EEAST, POL015 - Management f Incidents Plicy, V6.0 Page 9 f 21

10 Tabular timelines The five whys Fishbne analysis Reactive barrier analysis All findings shuld be dcumented in the investigatins screen f the Datix reprt. All evidence gathered during the curse f the investigatin must be attached via the Datix reprt dcuments sectin. Fr mre detail in relatin t hw t cnduct a rbust investigatin, please refer t the Investigatins Guidance V4.0, r cntact the Patient Safety Team fr supprt and training. 5.6 Duty f Candur In 2014 Duty f Candur came int frce as part f the Health and Scial Care Act. It is nw essential that the Trust is pen and hnest with patients and families where harm has ccurred. Where it is identified that harm r deteriratin has ccurred as a direct result f an incident, the Senir Lcality Manager (r equivalent), in cnjunctin with the Investigating Officer, must: Make persnal cntact (telephne r meeting) with the patient r their family Advise them f the incident Aplgise that the incident has ccurred Explain what the investigatin will include Ask whether the patient/family wishes t be invlved in the investigatin Offer a reprt nce the investigatin is included Fllw up this meeting r telephne call with a summary letter This must be cmpleted within seven days f the incident being reprted. If it has nt been pssible t make cntact with the patient r family, dcumentatin f the attempts made and the reasn fr n success must be dcumented within the Datix. A lack f address r family details is nt sufficient cnsideratin t surcing this infrmatin frm the patient s GP r in an instance f death the Crner is required. Fr mre infrmatin please refer t the Duty f Candur (frmerly Being Open) Plicy. 5.7 Outcmes and Identificatin f Learning Fllwing cmpletin f an investigatin, a cnclusin must be reached. The Trust advcates the principles f fair blame and recgnises that in the majrity f incidents, the rt causes f errrs are based in prcess and system errrs. The Incident Management system therefre wrks n the premise that investigatins are cnducted in a nn-punitive and supprtive manner, unless it is determined that a member f staff has knwingly acted in a reckless, intentinally unsafe r criminal manner. Ptential utcmes fr individual staff invlved: Discussins abut the case and the raising f awareness with regards t hw the incident can be avided. This includes reference t relevant plicies, prcedures and guidelines Reflective practice r persnal develpment with regards t the cause f the incident Additinal training Clinical debrief Referral t Clinical Variatins Panel, stage ne r stage tw If the investigatin evidences deliberate, unsafe r criminal acts, referral t the relevant HR prcess and referral t relevant prfessinal regulatry bdy (HCPC/GMC/NMC) if apprpriate. EEAST, POL015 - Management f Incidents Plicy, V6.0 Page 10 f 21

11 The Investigating Officer must determine whether the incident is likely t be an islated ccurrence related t the patient r individual staff invlved, r whether there is a likelihd f recurrence. In this instance, learning shuld be shared mre widely t minimise recurrence. This can include: Mems t staff within the team Team training Amendments t lcal prcesses (within the framewrk f Trust plicies and prcedures If it is felt that Trust wide learning is required, this shuld be escalated t the Patient Safety Team fr review and cnsideratin. Trust wide actins can include: Articles thrugh the Cmmunicatins team Additin t Prfessinal Update and Inductin Training New plicies/prcedures and guidelines 5.8 Feedback t Staff Onging cntact with the member f staff reprting the incident thrughut the curse f the investigatin is imprtant, in rder t ensure invlvement f the relevant persns in the investigatin. Upn cmpletin f an investigatin, when the incident has been finally apprved, datix generates autmatic feedback t the reprter f the incident thrugh the use f the supplied when the reprter reprted the incident. This ensures that feedback is always prvided. 5.9 Quality Assurance Fllwing cmpletin f an investigatin, the Investigating Officer will refer the incident t the Senir Lcality Manager (r equivalent) fr review and sign ff. The Manager is respnsible fr ensuring the investigatin has cvered the requirements and has identified apprpriate issues, learning and actin. Final clsure f an incident investigatin is cmpleted by the Patient Safety Team wh quality assure the prcess and identify any Trust wide learning r repeat incidents that may require mre rbust review. 6. Equality Impact Assessment The East f England Ambulance Service NHS Trust has made every effrt t ensure this plicy des nt have the effect f discriminating, directly r indirectly, against emplyees, patients, cntractrs, r visitrs n the grunds f race, clur, age, natinality, ethnic (r natinal) rigin, gender, sexual rientatin, marital status, religius belief r disability. This plicy will apply equally t full and part time emplyees. All East f England Ambulance Service NHS Trust plicies can be prvided in large print r Braille frmats if requested, and language line interpreter services are available t individuals wh require them. 7. Prcess fr Mnitring Cmpliance and Effectiveness The Executive Leadership Team has devlved respnsibility fr mnitring the Incident Management prcess t the Clinical Quality and Safety Grup (CQSG). Regular reprts identifying trends, remedial actin and any rganisatinal learning will be prepared by the Patient Safety Team fr submissin t the CQSG. Assurance papers will als be prvided by the Patient Safety Team t the Patient Safety and Care Standards Cmmittee fr Bard assurance purpses. EEAST, POL015 - Management f Incidents Plicy, V6.0 Page 11 f 21

12 Cmpliance with the plicy will be measured thrugh set standards and Key Perfrmance Indicatrs (sectin 8 belw). 8. Standards/Key Perfrmance Indicatrs Number f Incidents ccurring each mnth Prprtin f thse incidents invlving harm Timeframes fr investigatin cmpletin Feedback prvided t the staff reprting the incident Duty f Candur implemented where relevant 9. References Department f Health. (2004). Memrandum f understanding: Investigating patient safety incidents invlving unexpected death r serius untward harm: A prtcl fr liaisn and effective cmmunicatins between the Natinal Health Service, Assciatin f Chief Plice Officers and Health and Safety Executive. Lndn: Department f Health. Available at: and Natinal Patient Safety Agency (NPSA). (2005). Building a Memry: Preventing Harm, Reducing Risks and Prtecting Patient Safety. Lndn: NPSA. Available at: Natinal Patient Safety Agency (NPSA) Seven Steps t Patient Safety. The full reference guide. Available at Health and Safety Executive (HSE). The reprting f Injuries, Diseases, and Dangerus Occurrences Regulatins 1995 (RIDDOR). EEAST, POL015 - Management f Incidents Plicy, V6.0 Page 12 f 21

13 Appendix A - Example incidents and near misses (nt exhaustive) Examples f adverse incidents, near misses and ther hazards affecting clients, staff r members f the public: - slips, trips falls and cllisins - healthcare assciated infectin - incrrect treatment (e.g. failure t defibrillate when indicated) - any event which results in restraint f a patient by ambulance staff, regardless f sectin status r presence f ther services - medicatin errrs (e.g. wrng drug, incrrect dsage, incrrect time administered, cntra indicatins t drug nt assessed etc) - adverse reactin t medicines - accidental injury t a patient r client (e.g. damage t patient's ft during transfer) - accidental injury t emplyee r member f the public arising ut f wrk activities - all rad traffic accidents invlving Trust vehicles r vehicles used fr Trust activities n and ff Trust premises - inculatin, needle stick r sharps incidents - self-harm incidents - cntact with mving machinery r electricity - mving and handling incidents (including muscul-skeletal injuries) - physical r verbal abuse r threatening behaviur - medical device r equipment failure - cntact with harmful r hazardus substances - client, cntractr r staff use f alchl r illicit drugs n Trust premises - theft, lss r damage t client, staff r Trust prperty - clinical waste and general waste incidents (including spillage f hazardus substances, inapprpriate segregatin, labelling f waste - delay in diagnsis, wrng r incmplete diagnsis r incrrect patient assessment - suspected r actual abuse f vulnerable adults - unplanned release f hazardus substances int the envirnment - dangerus ccurrences that require reprting under the RIDDOR regulatins - security incidents - invlving peple, prperty, equipment and infrmatin - adverse incident invlving cntractrs and sub cntractrs, e.g. failure t bserve safety rules, pr attitude etc Examples f rganisatinal and system failures include: - breaches f gd clinical practice, plicies, prcedures r prtcls (r lack f them) - variance frm clinical pathway - health recrds nt available - lack f patient cnsent t treatment - cmmunicatin prblems between patient and healthcare staff - infrmatin arising frm client recrd reviews r audits - breach f cmputer passwrd security - cmputer viruses - lss f electrnic data - unauthrised access t IT systems - inapprpriate use f IT and Internet facilities, e.g. t dwnlad bscene material - failure f business cntinuity r cntingency plans - breach f cnfidentiality incidents - any breach f the law r statutry instrument - purchase f gds and services that d nt fllw the Trust s Prcurement Plicy r Standing Financial Instructins EEAST, POL015 - Management f Incidents Plicy, V6.0 Page 13 f 21

14 Appendix B Risk Matrix Purpse The purpse f the risk matrix is t prvide a cnsistent apprach t the grading f risks arising within the Trust, hwever and frm wherever, they are identified. This means that risks, whether identified frm, e.g.a health and safety risk assessment r a clinical incident r a legal claim r a cntrls assurance self-assessment, may be graded in the same cnsistent manner against the same generic criteria. The Trust Bard (and its sub-cmmittees) can then be cnfident that, when cnsidering risks within the same grading band, that these have been graded using the same methd and the same criteria. This will allw fr cmparisns between different types f risk and fr judgements and decisins t be made n that basis. Methd The accepted frmula fr grading risk is: Cnsequences x Likelihd This invlves making a judgement bth as t the Cnsequences t the persn(s) invlved and the Trust if the risk is realised, and the Likelihd (r prbability) f the risk ccurring, r recurring, and then allcating a number frm 1 t 5 t reflect this. The numbers represent the fllwing values: Cnsequences: Likelihd: 1 = insignificant 1 = rare 2 = minr 2 = unlikely 3 = mderate 3 = pssible 4 = majr 4 = likely 5 = catastrphic 5 = almst certain (In the case f a near miss, by definitin, n injury r damage has resulted. Hwever, in slightly different circumstances, injury r damage culd have resulted and it is the risk f this ptential injury r damage which shuld be graded.) Instructins fr use 1. Define the risk(s) explicitly in terms f the adverse impact that might arise frm the risk; 2. Use Table 1 (see belw) t determine the evidence based Impact scre(s) fr the ptential adverse utcme(s) relevant t the risk being evaluated; 3. Use Table 2 (see belw) t determine the evidence based Likelihd scre(s) fr thse adverse utcmes. If pssible scre the likelihd by assigning a predicted frequency f the adverse utcme ccurring. If this is nt pssible, assign a prbability t the adverse utcme ccurring within a given time frame, such as the lifetime f the prject r the patient care episde. If it is nt pssible t determine a numerical prbability, then use the prbability descriptins t determine the mst apprpriate scre. 4. Multiply the Impact Scre fr each f the descriptrs with the Likelihd Scre t btain the risk rating which shuld be a scre between 1 and 25; 5. Use the risk matrix, shwn belw t determine the clur banding fr the risk in respect f each descriptr (the highest scre will determine the verall risk level). EEAST_Management f Incidents Plicy_V3.2 Page 14 f 21

15 RISK MATRIX R (Risk) = C (Cnsequence) x L (Likelihd) CONSEQUENCES (IMPACT) LIKELIHOOD 1 - Insignificant 2 - Minr 3 - Mderate 4 - Majr 5 - Catastrphic 1 Rare Unlikely Pssible Likely Almst Certain When assessing the risk f an adverse event ccurring cnsideratin shuld be given t using the likelihd and the cnsequence tables belw. PROBABILITY DESCRIPTION RARE 1 in 100,000 chance DO NOT BELIEVE WILL EVER HAPPEN UNLIKELY 1 in 10,000 chance DO NOT EXPECT TO HAPPEN POSSIBLE 1 in 1000 chance MAY OCCUR OCCASIONALLY LIKELY 1 in 100 chance WILL PROBABLY OCCUR MOST CERTAIN 1 in 10 chance LIKELY TO OCCUR EEAST_Management f Incidents Plicy_V3.2 Page 15 f 21

16 Dmains Negligible Minr Mderate Majr Catastrphic Impact n the Minimal injury requiring Minr injury r illness Mderate injury requiring Majr injury leading t Incident leading t death safety f patients, staff r public (physical/ psychlgical harm) n/minimal interventin r treatment N time ff wrk required requiring minr interventin Requiring time ff wrk fr <3 days Increase in length f hspital stay by 1 3 days prfessinal interventin Requiring time ff wrk fr 4 14 days Increase in length f hspital stay by 4 15 days RIDDOR/agency reprtable incident An event which impacts n a small number f patients lng-term incapacity/ disability Requiring time ff wrk fr >14 days Increase in length f hspital stay by >15 days Mismanagement f patient care with lng-term effects Multiple permanent injuries r irreversible health effects An event which impacts n a large number f patients Quality/ cmplaints/ audit Peripheral element f treatment r service subptimal Infrmal cmplaint/inquiry Overall treatment r service sub-ptimal Frmal cmplaint (stage 1) Lcal reslutin Single failure t meet internal standards Minr implicatins fr patient safety if unreslved Reduced perfrmance rating if unreslved Treatment r service has significantly reduced effectiveness Frmal cmplaint (stage 2) Lcal reslutin (with ptential t g t independent review) Repeated failure t meet internal standards Majr patient safety implicatins if findings are nt acted n Nn-cmpliance with natinal standards with significant risk t patients if unreslved Multiple cmplaints/ independent review Lw perfrmance rating Critical reprt Incident leading t ttally unacceptable level r quality f treatment/service Grss failure f patient safety if findings nt acted n Inquest/ mbudsman inquiry Grss failure t meet natinal standards Human resurces/ rganisatinal develpment/ staffing/ cmpetence Shrt-term lw staffing level that temprarily reduces service quality (<1 day) Lw staffing level that reduces service quality Late delivery f key bjective/ service due t lack f staff Unsafe staffing level r cmpetence (>1day) Lw staff mrale Pr staff attendance fr mandatry/key training Uncertain delivery f key bjective/service due t lack f staff Unsafe staffing level r cmpetence (>5 days) Lss f key staff Very lw staff mrale N staff attendance fr mandatry/key training Nn-delivery f key bjective/service due t lack f staff Onging unsafe staffing levels r cmpetence Lss f several key staff N staff attending mandatry training/key training n an nging basis EEAST_Management f Incidents Plicy_V3.2 Page 16 f 21

17 Management f Incidents Plicy Dmains Negligible Minr Mderate Majr Catastrphic Statutry duty/ N r minimal impact Breech f statutry Single breech in Enfrcement actin Multiple breeches in inspectins r breech f guidance/ statutry duty legislatin Reduced perfrmance rating if unreslved statutry duty Challenging external recmmendatins/ imprvement ntice Multiple breeches in statutry duty Imprvement ntices Lw perfrmance rating Critical reprt statutry duty Prsecutin Cmplete systems change required Zer perfrmance rating Severely critical reprt Adverse publicity/ reputatin Rumurs Ptential fr public cncern Lcal media cverage -shrt-term reductin in public cnfidence Elements f public expectatin nt being met Lcal media cverage lng-term reductin in public cnfidence Natinal media cverage with <3 days service well belw reasnable public expectatin Natinal media cverage with >3 days service well belw reasnable public expectatin. MP cncern(questins in the Huse) Ttal lss f public cnfidence. Business bjectives/ prjects Insignificant cst increase/schedule slippage <5 per cent ver prject budget Schedule slippage 5 10 per cent ver prject budget Schedule Slippage Nn-cmpliance with natinal per cent ver prject budget Schedule slippage Key bjective nt met Incident leading >25 per cent ver prject budget Schedule slippage Key bjectives nt met Finance including claims Small lss Risk f claim remte Lss f per cent f budget Claim less than 10,000 Lss f per cent f budget Claim(s) between 10,000 and 100,000 Uncertain delivery f key bjective/lss f per cent f budget Claim(s) between 100,000 and 1 millin Purchasers failing t pay n time Nn-delivery f key bjective/lss f >1 per cent f budget Failure t meet specificatin/ slippage Lss f cntract/ payment by results Claim(s) > 1 millin Service/ business interruptin Lss/interruptin f >1 hur Lss/interruptin f >8 hurs Lss/interruptin f >1 day Lss/interruptin f >1 week Permanent lss f service r facility Envirnmental impact Minimal r n impact n the envirnment Minr impact n envirnment Mderate impact n envirnment Majr impact n envirnment Catastrphic impact n envirnment EEAST_Management f Incidents Plicy_V3.2 Page 17 f 21

18 Appendix C Investigatin Templates Tabular Timeline - template Plicy/Prtcl (What shuld >> have happened) Event date and time >> Event (What actually happened) >> Supplementary infrmatin Missing inf. / data gaps Ntable practice EEAST, POL015 - Management f Incidents Plicy, V6.0 Page 18 f 21

19 Fishbne template Cntributry Factrs identificatin grid EEAST, POL015 - Management f Incidents Plicy, V6.0 Page 19 f 21

20 Care and Service Delivery Prblem 1 Cntributry Factrs / Rt causes Patient Task Individual Staff Team and Scial Educatin and training Equipment / Resurces Cmmunicatin Wrking Cnditins Organisatinal / strategic Care and Service Delivery Prblem 2 Cntributry Factrs / Rt causes Patient Task Individual Staff Team and Scial Educatin and training Equipment / Resurces Cmmunicatin Wrking Cnditins Organisatinal / strategic EEAST, POL015 - Management f Incidents Plicy, V6.0 Page 20 f 21

21 Appendix D Equality Impact Assessment: Executive Summary Executive Summary Page fr Equality Impact Assessment: Dcument Reference: Dcument Title: Serius Incident Plicy Assessment Date: 2 January 2015 Dcument Type: Plicy Respnsible Directr: Tracy Nichlls (Directr f Lead Manager: Emma de Carteret (Risk Manager) Clinical Quality) Cnclusin f Equality Impact Assessment: N adverse impact n any grup r patient characteristic Recmmendatins fr Actin Plan: Nne Risks Identified: Nne Apprved by a member f the executive team: YES Name: Tracy Nichlls Psitin: Directr f Clinical Quality Signature: Date: 2/01/2015 This whle dcument shuld be stred with the master dcument and a final apprved electrnic cpy must be sent t the Equality & Diversity Lead at Bedfrd Office EEAST, POL015 - Management f Incidents Plicy, V6.0