Guidance on Serious Incident (SI) Reporting, Management and use of the Strategic Executive Information System (STEIS)

Transcription

1 West Midlands Strategic Health Authority Guidance on Serious Incident (SI) Reporting, Management and use of the Strategic Executive Information System (STEIS) Produced by the Clinical Quality & Patient Safety Team NHS Midlands and East, West Midlands Strategic Health Authority Version 1:1 April 2012 NHS West Midlands is part of the NHS Midlands and East cluster of SHAs comprising NHS East Midlands, NHS East of England and NHS West Midlands. Page 1 of 66

2 Contents Chapter Description Page Introduction Understanding STEIS 1 Logging On 2 Opening the Serious Incident area & Reporting 3 Adding a New Incident 4 Using the STEIS SI reports facility Appendices Description Page Appendix A Key Questions Prompt Cards Appendix B Definitions of SI Categories Appendix C Useful Associated Documents and Links Clinical Quality & Patient Safety Team at NHS Midlands and East, West Midlands Office Author(s) Catherine McInerney Clinical Quality and Patient Safety Manager Elaine Thompson - Clinical Quality and Patient Safety Manager Pauline Werhun Interim Clinical Quality and Patient Safety Manager Ian Baker - Clinical Quality and Patient Safety Administrator Version Version 1.0 Ratified by Manjeet Garcha Head of Clinical Quality and Patient Safety Last updated 25 April 2012 Date 25 April 2012 Page 2 of 64

3 Introduction This information guide which has been developed by the Clinical Quality & Patient Safety Team at NHS Midlands and East, West Midlands Office and focuses onto Serious Incident (SI) Reporting, Management and use of the Strategic Executive Information System, commonly referred to as STEIS. This information guide has been developed to support best practice in respect to: Serious incident reporting Use of the STEIS system This information guide builds upon the Serious Untoward Incident (SUI) Reporting User Guide, Issue 1 (November 2003), the National Patient Safety Agency (NPSA) National Framework for Reporting and Learning from Serious Incidents requiring Investigation (March 2010) and other professional sources. Primarily this information guide has been produced to support the planned devolvement of serious incident management to PCT Clusters across the West Midlands region. However it also serves as part of the governance legacy for organisations in respect to serious incident management. Understanding STEIS The Serious Incident (SI) system is one of the modules of the Strategic Executive Information System (STEIS). STEIS allows users to report and view (depending on access rights) Serious Incidents for their areas of responsibility. The SI module enables electronic logging, tracking and reporting of Serious Untoward Incidents. Once an incident is raised by a Trust and entered into the SUI module, an alert is sent to nominated officers at the SHA/PCT Cluster, who will be ultimately responsible for closing an incident. Once closed the information is still available to view as a read-only file. The STEIS Helpdesk offers an and telephone service ( Monday to Friday) on all aspects of the STEIS application including the issue of passwords to nominated SHA leads, update of the "News" page, help on navigation etc. Queries about specific data items, including data definitions, should be addressed to the specific data contacts. Page 3 of 64

4 Chapter 1 Logging On The STEIS system is on the NHS Web and the address is This will take you to the webpage below: The two key features of this page are: System Advice & Guidance helpful guidance & advice is available through clicking on STEIS system news & tools section Untoward Incidents which takes you to the Serious Incident area of STEIS Page 4 of 64

5 Chapter 2 Opening the Serious Incident area (Untoward Incidents) By clicking on the Untoward Incidents option you will be prompted to enter your trust username and password: NOTE: STEIS does not provide individual passwords for each user; every NHS organisation has a shared password You should have been provided with a username and password for the system from your SHA/PCT Cluster SI Lead. The password is case sensitive and should be in lower case. If you have difficulty logging on to the system contact your nominated SI lead at the SHA/PCT Cluster in the first instance. A new page will then be displayed (see below) Page 5 of 64

6 Options on the SI Home Page & Reporting There are 4 sections in the main body of the home page with further options available in the menu bar at the top of the page: My Ongoing Incidents these options allow you to access all incidents within your area, grouped by Trust name, with the option to sort by date reported Recently Updated Incidents DO NOT USE this section should display all incidents modified in the past 7 days, however note that the results displayed are not accurate. Reports this allows you to view a variety of reports related to incidents reported by your Trusts. Incident by Log No is probably the most useful, displaying all reported SIs by date reported, with the most recent at the top of the list. The New Search function in the menu bar at the top of the page is also an extremely useful reporting tool and will be discussed in more depth later in this section. B/Fwd Date past this allows you to view incidents where the Bring forward date has passed. When an incident is logged the Bring Forward date is automatically populated as one month after the date of reporting. Additional Options in menu bar (visible in most sections of STEIS): STEIS home: takes you to STEIS homepage discussed on the previous page of this guide Home: returns you to the STEIS Homepage Add an incident: to report a new SI All incidents: displays all incidents logged in your area, both open and closed Summary reports: allows you to run a summary of the numbers of SIs reported at your trust (or a selection of trusts in the case of Clusters) with the option to select a date range. When running the report you are given the option to produce the report as either a CSV or XML file. CSV is generally the more useful option as this can then be saved as an Excel file. Search all incidents: performs a keyword search of all incident records, this function is also used if you wish to search for a particular incident by entering the STEIS reference number. Change password: takes you through the process of change the organisations STEIS user password. NB Changing passwords should only be considered if there is concern about the password security. Page 6 of 64

7 New Search: This function allows you to run a bespoke report using a number of search criteria: Step 1 Select the search criteria Date incident reported OR date incident occurred Reporting trust (in the case of PCT Clusters) Incident category by default the report selects all incident types, to search for only those of a particular type, left click the relevant category. Note you can select multiple categories by simply holding down the Ctrl key and selecting key headings from the dropdown selection. Incidents grade by default the report selects all grades Incident status by default the report selects all statuses If the Never Event box has been ticked (please be aware this box was only added to STEIS in late 2011 so selecting this option may not highlight all Never Events) Page 7 of 64

8 Step 2 Select the fields required Below the reporting criteria options there is box inviting you to select SUI fields for export, ie which fields are displayed on the final report. By default all fields are selected, however as previously mentioned, you can select multiple categories by simply holding down the Ctrl key and selecting key headings from the dropdown selection. Step 3 Run the report Click the Save your search button. You will then see the message box below, click okay. Although the message box states the report will be complete in 15 minutes, it is often considerably more than this. Note that more detailed reports may need to run overnight. Step 4 Viewing your report Immediately after you have run the report you will be taken back to the SI reporting home page. The report you have just run will appear in the View Search Query (unprocessed) section (the link to which is in the menu bar at the top of the page). When the report is complete and ready to view it will appear in the View Search Query (Completed) section. At this point click view search output to be presented with the page below: Click the SUI0.csv link at the bottom of the page to open the report as an excel file. Page 8 of 64

9 Adding a New Incident Chapter 3 Click on the Add an Incident option on the Menu Bar to open a blank incident e-form. The form consists of various drop-down menus and free text areas. By hovering over any of the? symbols, guidance on how to complete that area will appear in the form of a pop-up help box. Section 1 Reporting Organisation detail - some of the form will be pre-populated with details matching the log-on id of the organisation. A Log number is automatically assigned when a new e-form is opened and is unique to that incident. It is important to keep a note of this log no. in case of STEIS system failure. This will allow the record to be identified and accessed. Please note that this log number should be used in any correspondence between the Organisation and the SHA/PCT Cluster so as to maintain confidentiality. Note that each incident has a unique STEIS number The first four digits e.g. 2009/ will indicate the year that the incident was logged onto the STEIS system. The remaining digits indicate the number allocated to that incident from the national system. The Bring forward date will appear when the form is completed and the appropriate bring forward date for the incident is entered further down the form. This date can be altered as the investigation progresses. (The system automatically sets this date 1 month from the date of entering the information. This can be overwritten and the appropriate date entered). Page 9 of 64

10 Section 2 When, Where, Your Details Date of incident is the date the incident occurred, not the date it was entered onto STEIS. The date format throughout the form should be entered as dd/mm/yyyy. If it is not known when entering the information, this field should be left blank and the date added later. Time of incident should be completed using 24 hour clock format and should be entered hh:mm. If the time is not known this field should be left blank. Site of incident is used when a Trust has more than 1 site or where a PCT needs to enter the premises where the incident happened. Location of incident is a drop down box and has the option other which can be used if the location is not specified in the drop down list. Reporter s details which are given should be someone within the reporting organisation who can be contacted by the SHA/PCT Cluster who is able to provide further information if necessary, this may be the person logging the incident on STEIS. Remember to include an accurate address and telephone number. Section 3 Who Detail related to Care sector, Clinical area and Type of patient is recorded using drop down boxes. Ensure that the information captured here is as accurate as possible. Under clinical area it is possible to select more than one category. To do this hold the Ctrl key down whilst clicking on your selections. Gender - more than 1 box can be ticked where appropriate (i.e. more than one patient involved) or left blank. Date of birth- Must be entered dd/mm/yyyy. If the date of birth is not known this field can be left blank. Ethnic group-is a drop down box and must only be categorised if the person s ethnicity is definitely known, otherwise the category not stated should be selected. Page 10 of 64

11 Section 4 What Happened? Type of incident should be selected from the drop down box. Where possible avoid the use of Other NB This will default to Abscond so please ensure that you ensure that the correct category is picked. Actual/near miss - tick the actual box if an incident actually occurred. The near miss box should be ticked if an SUI was narrowly averted. Grading Choose relevant incident grade from drop down box (0/1/2). Every incident must be graded as 0, 1 or 2. Do not leave an incident graded at 0 for more than 3 working days. Never Event (recent additional field - Oct 2011). This will default to No click to amend if the incident has been confirmed as a Never Event. Description of what happened - Brief but concise information should be added here which describe the details of what it is understood actually happened. Do not use patient or staff identifiable information. Also please avoid using abbreviations or acronyms (other than those universally understood i.e. A&E). This will reduce the chance of misunderstanding as these can be used in different specialties with different meanings. In cases where abbreviations or acronyms are used then ensure that the full meaning is used at least once. Providing the information in chronological order, using a simple timeline helps provide clarity around how events unfolded and the incident occurred. Try to avoid relying on cut and paste from local incident forms as these do not always provide the full information required to support external reporting of Serious Incidents. Page 11 of 64

12 Section 4 (cont) Case summary for the weekly bulletin is completed by the SHA/PCT Cluster and is a summarised version of what happened. This section forms the basis of all SI reports within the system. Immediate action taken - Brief but concise information should be added here which describes the details of what actions were taken to ensure that there was no further escalation of incident / harm to individual, and that any immediate patient safety risks were addressed. Confirm whether Being Open principles have been followed and how staff /patients/ relatives are being supported. Include here details of other bodies that have been informed or may be investigating the incident i.e. Police, Coroner, Confidential Enquiries (i.e. CEMACH / NCEPOD / NCISH) Health and Safety Executive, NPSA, Health Protection Agency etc. Entering accurate relevant data at this point is crucial in ensuring that the Trust/PCT/SHA have clear information and can provide upward assurance that the incident is being appropriately handled. Further Information is used to provide an update as more information becomes available and the investigation into the incident progresses. When entering information here ensure that the date & details of the person entering the update is recorded. Media interest and line being taken by the Trust/PCT If there is known media interest in the case it is mandatory for the line being taken to be completed to ensure the SHA will know as soon as possible what is going on and what the recommended corporate response should be in the event that the organisation is contacted by the media. Externally reportable Click on which body the incident needs to be reported to. If reportable to more than one body, hold the control key down and click on your selection. Apparent outcome, likelihood of recurrence, most likely consequences and potential risks to future patients - these fields are from the original National Patient Safety Agency minimum data set and at this time need only be filled if mandated by SHA /PCT Cluster. Page 12 of 64

13 Lead officer Identify who the Trust lead officer for this incident is and ensure that their contact details are added. This is likely to be a senior manager/clinical lead /executive lead designated by the organisation as the most appropriate point of contact for the incident/investigation. Make sure their contact details (name/title/telephone/ address) are accurately recorded this will ensure that further queries by the SHA/PCT Cluster can be directed quickly to the most appropriate person. Current file holder Identify who the current file holder is if it different individual from the Lead Officer. The Bring forward date will be automatically generated when the e-form is created. The system automatically sets this date 1 month from the date of entering the information. This can be overwritten and the appropriate date entered). Reports - Choose from the drop down box the most appropriate descriptor (guidance below) Independent Inquiry Internal Inquiry Serious Case Review Request for Further Information This should be used if there has been a Homicide or if an Independent Chair or External advice is sought as part of an investigation. This report is used for most incidents. Used in the case of child protection. When more information is needed before the internal investigation report is completed. Correspondence history this field is used for a summary of correspondence details. Remember at all times to clearly identify the date & the details of person making entry on the record, for example:- 29/11/11 - Letter / sent to the Coroner re: inquest. F. Smith Quality & Safety Officer, St Elsewhere NHS Trust 02/12/11 - Letter / received from SHA/PCT Cluster requesting update. N. Jones Head of Patient Safety, Middle Earth PCT Cluster Please note that the information entered here does not replace the need to send a copy of the internal report to the SHA/PCT Cluster Comments Any comments regarding the progress of the case can be entered into this field. This information is pulled through into the bring forward date report. Once again, as previously mentioned, please remember to clearly identify the date & the details of person making entry on the record. Page 13 of 64

14 Root cause and Lessons learned When the investigation is finished and the Trust/PCT has completed the root cause analysis, the root causes, actions planned and any lessons learned should be entered in this field. This information should demonstrate that the Trust have done all they can to reduce the chance of a similar incident happening again and that learning has taken place. When completing this section it is essential to ensure that information is included that will provide assurance, both internally & externally, that the key issues have been identified and that appropriate actions have been taken to address those issues. Dissemination of Lessons Learned It is important to clearly identify how the lessons learned will be disseminated within the organisation. The information recorded on STEIS should demonstrate a clear thread that identifies: 1. The root cause(s) 2. How these directly resulted in the specific care and service delivery problems. 3. How these contributed to the actual or potential effect on the patient. 4. An action plan that addresses identified issues with timescales. 4. How lessons learned have been disseminated and practice changed where appropriate. Saving the SI e-form Once the form is completed, clicking on Save as Draft will save the data entered but will not send the alert to the SHA/PCT Cluster. However please note that the SHA/PCT Cluster can still view draft incidents. As a result of this please do not leave an incident in draft for longer than 24hrs. Clicking on Save will save the entry and send an alert to nominated individuals at the SHA/PCT Cluster. Editing the SI e-form To edit an incident, click on the edit link next to the e-form you wish to edit, and the form will open up. Enter/change the data, and click the Save button at the top of the page. Please note that the SHA/PCT Cluster is not automatically notified when you have edited an incident, and therefore you may need to advise them. Closing an Incident Untoward Incidents can only be closed by the SHA/PCT Cluster when they are satisfied that the incident has been fully investigated and any actions and/or recommendations have been addressed. The root cause and lessons field should also be completed. On the very rare occasion when there is no learning from the incident the field could read no learning applicable in this case. Note that when an incident has been closed it can still be read on the System or printed. Page 14 of 64

15 Re-opening Incidents An incident can be re-opened if new information becomes available or if further investigation is warranted. To have an incident re-opened contact your SHA/PCT Cluster lead who will make the necessary arrangements. Deleting Incidents If an incident is duplicated or put on the system in error it can be deleted from the system. To have an incident deleted contact your SHA/PCT Cluster lead who will make the necessary arrangements. Please note that an entry must always be made onto STEIS to explain the rationale of why an incident is being deleted. This is essential as it serves to provide a robust corporate record. Page 15 of 64

16 Using the STEIS SI reports facility Chapter 4 The following reports can be generated and printed out. They can also be cut and pasted into word documents and manipulated to suit your organisational requirements. Page 16 of 64

17 Weekly Bulletin is shown in the format below. You can either define the dates, if more than one week is required, or select the required week. When you have made your selection the following page is opened Page 17 of 64

18 Incidents by Organisation - this report shows the number of incidents that have been logged in a given organisation. See example below which shows incidents by organisation for the North, Anytown SHA and Trust/PCT When you click on the expand key it shows incidents by organisation for the North, Anytown SHA and Trust/PCT, giving log number, date of incident, last 3 characters of Trust username and a link directly to the incident. Trusts /PCTs will only see their own information and the SHA/PCT Clusters will see all the information in their area. Page 18 of 64

19 Incidents by Type This report shows the total number of incidents logged in the system by type. The expanded view shows the total number of incidents by type, for the North, SHA and Trust/PCT. Page 19 of 64

20 Incidents by Care Sector This report can be viewed in either of the formats below and shows the total number that have been logged in the system. The expanded view shows the total number logged in the system for each care sector, then the log number, date of incident, type of incident and a link that enables you to open the incident. Page 20 of 64

21 Incidents by File Holder- Shows the number of files currently held by individuals within the organisation The expanded view shows, as well as the number of files per person, which files they actually hold. This report makes it easy to review case loads etc. Incidents by Lead Officer - this report shows at a glance who the lead officer within the organisation is for each case. Page 21 of 64

22 By Lead Officer (cont)- The expanded view shows the lead officer, number of cases, log number and incident type. Any incident can be accessed from this area via the link. Incidents by Bring Forward Date- Lists all the bring forward dates that the organisation has entered into the system. The expanded view shows the bring forward date, a summary of the incident and any comments the organisation has made in the comments box. Page 22 of 64

23 Search all incidents Clicking on this option will open up the following screen: Complete the details required (enter keywords and/or dates you wish to search for) and click on the search button. Any returns matching your criteria will be listed in the results. Page 23 of 64

24 Appendix A West Midlands Strategic Health Authority Key Questions - Prompt Cards (PC) What are Key Questions Prompt Cards? The Key Questions Prompt Cards have been developed to provide Commissioners and Providers with a short list of key points or issues that they may wish to explore as part of the Serious Incident Investigation process. The list of prompts is not exhaustive and hence should always be supported by local agreement of incident specific issues requiring review or assurance. Page 24 of 66

25 Key Questions Prompt Cards Index Topic Pg No Topic Pg No Topic Pg No Abscond (PC1) 26 Accident Whilst in Hospital (PC2) 27 Admission of an under 16 or under 18 in 28 Mental Health (PC3) Allegation against HC Professional or 29 Assault (PC5) 30 Bogus Health Workers (PC6) 31 Non-Professional (PC4) Chemical incident (PC7) 32 Child Abuse (PC8) 33 Child Death (PC9) 34 Child Injury (PC10) 35 Communicable Disease and Infection 36 Confidential Information Leak (PC12) 37 Issue (PC11) Delayed diagnosis (PC13) 38 Drug incident (PC14) 39 Failure to act upon test results (PC15) 40 Failure to obtain consent (PC16) 41 Fire accidental or non-accidental 42 Homicide / Attempted Homicide (PC18) 43 (PC17) Hospital / Medical equipment failure 44 Maternity Incidents (PC20) 45 Pressure ulcer (PC21) 46 (PC19) Radiology incidents (PC22) 47 Scanning incidents (PC23) 48 Safeguarding Vulnerable Adult or Child 49 (PC24) Screening Issues (PC25) 50 Serious Self Inflicted Injury/ Attempted 51 Slips/Trips/Falls (PC27) 52 Suicide (PC26) Sub-optimal care of the deteriorating 53 Suicide (PC29) 54 Surgical Error (PC30) 55 patient (PC28) Unexpected Death (PC31) 56 Venous Thromboembolism (VTE) (PC32) 57 Wrong site surgery (PC33) 58 Page 25 of 64

26 Abscond - Key Questions - Prompt Card (PC1) What happened within the incident? establish timeline Was the patient known to be an absconding risk before this incident? If YES, did they have an appropriate care plan in place? What level of observation was in place at the time of the incident, and was this appropriate given the patients known absconding history? Was observation being delivered in accordance with agreed best practice?** Were the appropriate individuals notified that the patient had gone missing? Has the patient returned? How was the patient on return? Was the level of observation increased when the patient returned? Did this incident take place at a known high risk time e.g. shift handover, mealtime, drug round etc? Has a post-incident debrief taken place? What section of the Mental Health Act was the patient detained under at the time of the incident? Is the abscond reportable to the Care Quality Commission?** Key Points to Consider Have there been similar absconding incidents in that area? If YES, had the previous root causes been adequately addressed and any changes embedded into practice? Had clinical staff received relevant training in respect to reducing the risks of missing patients? Was the Missing Patient Policy utilised effectively within this incident? Has the Missing Patient Policy been revised or amended following this incident? Has the patient been asked why they absconded? Have the lessons learnt from this incident been shared appropriately? Has the route that the patient used to abscond been identified? Was this exit point alarmed? If NOT, have appropriate controls now been put into place to reduce the risks of reoccurrence? Is local practice in respect to reducing incidents of missing patients in line with identified best practice? ** **Further information contained in Appendix C Page 26 of 64

27 Accident Whilst in Hospital - Key Questions - Prompt Card (PC2) What was the nature of the accident? What happened within the incident? establish timeline Who was affected by this incident? What was the nature and extent of injuries? Did this incident involve any hospital equipment? If YES, what was the model, make and serial number? Have there been any national alerts issued in respect to this equipment? Is the incident RIDDOR reportable? ** What controls have been put into place post-incident to reduce the risks of reoccurrence? Key Points to Consider Could this accident have been foreseen? Have there been any similar incidents within the area? If YES, had the previous root causes been adequately addressed? Has this incident identified any areas that need to be changed within policies/procedures/guidance? If YES, has these changes been embedded into practice? Have the lessons learnt from this incident been shared appropriately? **Further information contained in Appendix C Page 27 of 64

28 Admission of an under 16 or under 18 in Mental Health - Key Questions - Prompt Card (PC3) What happened within the incident? establish timeline Why was admission to hospital necessary? Were all efforts made to secure an age-appropriate bed prior to admission? What level of observation has the young person been placed on? Key Points to Consider What measures have been put into place to ensure that the young person receives age-appropriate care and treatment? What is the young persons reaction to admission? Has the Care Quality Commission been notified of admission in accordance with CQC guidance? ** Did the young person have appropriate contact from CAMHS during their admission to hospital? Was the local Safeguarding Lead informed of the admission to hospital? Had staff involved in the incident received appropriate safeguarding training? Had staff involved in the incident received appropriate training in respect to the management of an under 18 admission? Has the service got a policy in place concerning the admission of under 18s to adult mental health in-patient facilities? If YES, was this policy followed? Have the lessons learnt from this incident been shared appropriately? **Further information contained in Appendix C Page 28 of 64

29 Allegation against HC Professional or Non-Professional - Key Questions - Prompt Card (PC4) What happened within the incident? establish timeline What is the nature of the allegation that has been made against the healthcare worker? What controls have been put into place to protect patients? Key Points to Consider Had staff involved in the incident received appropriate safeguarding training? What controls have been put into place post-incident to reduce the risks of reoccurrence? Have there been any similar incidents within the area? What controls have been put into place to support the healthcare worker? What controls have been put into place to support other team members affected by this incident? Has the healthcare worker been suspended from duties? If NOT what controls have been put into place to safeguard others during the period of investigation? Is there any Police involvement? Has a decision been made in respect to informing the relevant professional bodies (as appropriate)? If YES, had the previous root causes been adequately addressed? Has this incident identified any areas that need to be changed within policies/procedures/guidance? If YES, has these changes been embedded into practice? Have the lessons learnt from this incident been shared appropriately? Page 29 of 64

30 Assault - Key Questions - Prompt Card (PC5) What happened within the incident? establish timeline What was the nature of the assault? What was the nature and extent of injuries? Key Points to Consider Had staff involved in the incident received appropriate training in the prevention and management of violence and aggression? What controls have been put into place post-incident to reduce the risks of reoccurrence? Have there been any similar incidents within the area? Who was affected by this incident? Did the alleged perpetrator have a known history of aggressive behaviours and/or threats to others? If YES, was this information known before the incident? Is there any Police involvement? If YES, have charges been brought against the alleged perpetrator? Has the local Security Management Specialist been informed of this incident? Was the local Security Management Specialist actively involved in the incident investigation? Did this incident involve the use of a weapon? If YES, was this removed from the alleged perpetrator? Has post-incident debriefing taken place? If YES, had the previous root causes been adequately addressed? Has this incident identified any areas that need to be changed within policies/procedures/guidance? If YES, has these changes been embedded into practice? Have the lessons learnt from this incident been shared appropriately? Page 30 of 64

31 Bogus Health Workers - Key Questions - Prompt Card (PC6) What happened within the incident? establish timeline How was the service alerted to this incident? Did the bogus health worker manage to gain access to any patients? If YES, have patients concerned been informed? Key Points to Consider Did the bogus health worker manage to gain access to any patient identifiable data? If YES, have patients concerned been informed? Have the Police been informed of this incident? If YES, what actions have been taken? Is it clear how the bogus health worker managed to access the service? What controls have been put into place post-incident to reduce the risks of reoccurrence? Has this incident identified any areas that need to be changed within policies/procedures/guidance? If YES, has these changes been embedded into practice Have the lessons learnt from this incident been shared appropriately? Page 31 of 64

32 Chemical incident - Key Questions - Prompt Card (PC7) What happened within the incident? establish timeline What is the nature of the incident? chemical involved What are the known risks of exposure to this chemical? Have any staff / patients/ visitors been affected by this incident? Key Points to Consider If YES, what is the extent of their exposure and how will this affect them in the short and long term? Have any clinical areas been closed as a result of this incident? If YES, what measures have been put into place to ensure service continuity? Has the local Health and Safety Officer reviewed this incident? What controls have been put into place post-incident to reduce the risks of reoccurrence? Has this incident identified any areas that need to be changed within policies/procedures/guidance? If YES, has these changes been embedded into practice? Have the lessons learnt from this incident been shared appropriately? Page 32 of 64

33 Child Abuse - Key Questions - Prompt Card (PC8) What happened within the incident? establish timeline What was the nature of the abuse? How long has the child been at risk? What contact has the child had with health and social care services? Were the actual or potential risks of abuse known prior to this incident? If YES, what controls were in place to protect the child and why did they fail? Key Points to Consider Had staff involved in the incident received appropriate safeguarding training? Are there any other individuals who may be at risk e.g. other siblings or a parent in an abusive relationship? If YES, what actions have been taken to safeguard these individuals from potential or further abuse? What controls have been put into place post-incident to reduce the risks of reoccurrence? Have there been any similar incidents within the area? If YES, had the previous root causes been adequately addressed? Has the local Safeguarding Lead been informed of this incident? Was the local Safeguarding Lead actively involved in the incident investigation? Where is the child now how are they being supported and cared for? Where is the alleged perpetrator what action(s) have been taken against them? Have the Police been informed of this incident? If YES, what actions have been taken? Will this case be subject to a Serious Case Review? Has this incident identified any areas that need to be changed within policies/procedures/guidance? If YES, has these changes been embedded into practice? Was this case subject to a Serious Case Review? If YES, what were the findings? Have the lessons learnt from this incident been shared appropriately? Page 33 of 64

34 Child Death - Key Questions - Prompt Card (PC9) What happened within the incident? establish timeline How did the child died document cause of death once known Were there any safeguarding concerns? If YES, what controls were in place to protect the child and why did they fail? Key Points to Consider Was the local Safeguarding Lead actively involved in the incident investigation? Had staff involved in the incident received appropriate safeguarding training? What controls have been put into place post-incident to reduce the risks of reoccurrence? Have there been any similar incidents within the area? What contact has the child had with health and social care services? Will the death be subject to a Serious Case Review? If YES, what was the outcome of this Serious Case Review? Has the local Safeguarding Lead been informed of this incident? Has this death been referred to the Child Death Overview Panel (CDOP)? Was this an unexpected death? If the death was unexpected what made it so? If YES, had the previous root causes been adequately addressed? Has this incident identified any areas that need to be changed within policies/procedures/guidance? If YES, has these changes been embedded into practice? Was this death referred to the Child Death Overview Panel (CDOP)? If YES, what were the findings? Have the lessons learnt from this incident been shared appropriately? Page 34 of 64

35 Child Injury - Key Questions - Prompt Card (PC10) What happened within the incident? establish timeline What is the nature of the injury? Was this injury accidental or non-accidental in nature? What was the cause of the injury? What has been the impact of this injury on the child? Are there any safeguarding concerns? If YES, what actions have been taken? Key Points to Consider Are there any other individuals who may be at risk e.g. other siblings or a parent in an abusive relationship? If YES, what actions have been taken to safeguard these individuals? Had staff involved in the incident received appropriate safeguarding training? Has this incident identified any areas that need to be changed within policies/procedures/guidance If YES, has these changes been embedded into practice? Have the lessons learnt from this incident been shared appropriately? Page 35 of 64

36 Communicable Disease and Infection Issue - Key Questions - Prompt Card (PC11) What happened within the incident? establish timeline What is the nature of the communicable disease or infection control incident? Who has been affected by this? patients, staff, visitors What measures have been taken to reduce risks of cross infection? Key Points to Consider Has the local Infection Prevention and Control Lead been informed of this incident? Have there been any similar incidents within the area? If YES, had the previous root causes been adequately addressed? Has the local Infection Control Committee been advised of the incident and the outcome of the root cause analysis? Has this incident identified any areas that need to be changed within policies/procedures/guidance? If YES, has these changes been embedded into practice? Was the local Infection Prevention and Control Lead actively involved in the incident investigation? Have any clinical areas been closed as a result of this incident? If YES, what measures have been put into place to ensure service continuity? What controls have been put into place post-incident to reduce the risks of reoccurrence? Where appropriate, have other internal/external agencies been notified e.g. HPA, PCT, mandatory surveillance systems, communications? Has the incident been escalated via all appropriate internal pathways e.g. Serious incident reporting and HCAI reporting? Have the lessons learnt from this incident been shared appropriately? Page 36 of 64

37 Confidential Information Leak - Key Questions - Prompt Card (PC12) What happened within the incident? establish timeline What is the nature of the confidential information leak? What type of information has been lost? paper, electronic How has the information been lost? human error, theft, system failure Who is affected by this loss, and have they been informed? Has the local Information Governance Lead been informed of this incident? Was the local Information Governance Lead actively involved in the incident investigation? Has the local Caldicott Guardian been informed of this incident? Key Points to Consider Has the level of the Information lost within this incident been rated in accordance with the Department of Health guidance Checklist for Reporting, Managing and Investigating Information Governance Serious Untoward Incidents ** In the event that the incident has been rated as a Level 3 or above, has the organisation informed the Information Commissioner? Does the loss of this information loss potentially impact onto any vulnerable groups? If YES, has the local Safeguarding Lead been informed? What controls have been put into place post-incident to reduce the risks of reoccurrence? Have there been any similar incidents within the area? If YES, had the previous root causes been adequately addressed? Has this incident identified any areas that need to be changed within policies/procedures/guidance? If YES, has these changes been embedded into practice? Have the lessons learnt from this incident been shared appropriately? **Further information contained in Appendix C Page 37 of 64

38 Delayed diagnosis - Key Questions - Prompt Card (PC13) What happened within the incident? establish timeline Why was the diagnosis delayed? How was the patient affected by this delay in diagnosis? Has the patient been informed of the fact that their diagnosis was delayed? If YES, how have they reacted to this? Has the organisation taken measures to confirm whether any other patients have experienced similar delay? Key Points to Consider Have there been any similar incidents within the area? What controls have been put into place post-incident to reduce the risks of reoccurrence? If YES, had the previous root causes been adequately addressed? Has this incident identified any areas that need to be changed within policies/procedures/guidance? If YES, has these changes been embedded into practice? Have the lessons learnt from this incident been shared appropriately? Page 38 of 64

39 Drug incident - Key Questions - Prompt Card (PC14) What happened within the incident? establish timeline What was the nature of the drug incident? Key Points to Consider Was the local Medicines Management Lead actively involved in the incident investigation? Has the root cause of this incident been identified? What should the patient have received and what did they actually receive? What were the consequences to the patient of this drug error? Did they require additional treatment or therapy? Has the patient been informed about the drug error? YES, how have they reacted to this? Did this incident take place during a protected drug round? Did this incident involve a drug that was not normally used within that clinical environment? Was this incident identified as a Never Event? If YES, did a level 2 incident investigation take place? Has the local Medicines Management Lead been informed of this incident In the event that the incident involved a Controlled Drug has the designated responsible Officer and the Controlled Drug Local Intelligence Network been informed? What controls have been put into place post-incident to reduce the risks of reoccurrence? Have there been any similar incidents within the area? If YES, had the previous root causes been adequately addressed? Has the local Medicines Management Committee been advised of the incident and the outcome of the root cause analysis? Has this incident identified any areas that need to be changed within policies/procedures/guidance? If YES, has these changes been embedded into practice? Have the lessons learnt from this incident been shared appropriately? Page 39 of 64

40 Failure to act upon test results - Key Questions - Prompt Card (PC15) What happened within the incident? establish timeline How did the service become aware of this incident? What were the test results that staff failed to act upon? What were the consequences to the patient of this incident? Did the patient require additional treatment or therapy? Has the patient been informed of this incident? If YES, what was their reaction? What type of monitoring was in place for the patient at the time of the incident? Key Points to Consider Was this monitoring effective in alerting staff to the failure to act upon test results? Has the root cause of this incident been identified? What controls have been put into place post-incident to reduce the risks of reoccurrence? Has the organisation taken measures to identify whether any other patients who may have had their test results missed? Has this incident identified any areas that need to be changed within policies/procedures/guidance? If YES, has these changes been embedded into practice? Have the lessons learnt from this incident been shared appropriately? Page 40 of 64

41 Failure to obtain consent - Key Questions - Prompt Card (PC16) What happened within the incident? establish timeline What is the normal procedure for consent within the organisation? What level of consent should have been obtained? What factors contributed to the failure to obtain consent? Was this consent written or verbal? Had the patients mental capacity been assessed? Was the patient considered to be vulnerable? If YES, has the local Safeguarding Lead been informed of this incident? Has the patient been informed of this incident? If YES, what was their reaction? Has national guidance been following in respect to Consent?** Key Points to Consider What systems are in place within the organisation for ensuring best practice in respect to gaining consent? Had staff involved in this incident received appropriate consent training? Has this incident identified any areas that need to be changed within policies/procedures/guidance? If YES, has these changes been embedded into practice? Have the lessons learnt from this incident been shared appropriately? **Further information contained in Appendix C Page 41 of 64

42 Fire accidental or non-accidental - Key Questions - Prompt Card (PC17) What happened within the incident? establish timeline How did the fire impact onto patients and the service? Was anyone injured? If YES, what was the nature and degree of the injuries sustained? Was there any property damage? If YES, what was the nature and degree of the damage sustained? Have any clinical areas been closed as a result of this incident? If YES, what measures have been put into place to ensure service continuity? Has the cause of the fire been identified? Has the local Fire Safety Officer been informed of this incident? Was the Emergency Response to the fire appropriate? In the event of alleged Arson, have the Police been informed? If YES, what actions have been taken? Key Points to Consider Have individuals affected by this incident received appropriate post-incident support/debriefing? Had staff involved in this incident received appropriate fire training? Has this incident identified any areas that need to be changed within policies/procedures/guidance? If YES, has these changes been embedded into practice? Have the lessons learnt from this incident been shared appropriately? Page 42 of 64

43 Homicide / Attempted Homicide - Key Questions - Prompt Card (PC18) What happened within the incident? establish timeline Is the alleged perpetrator known to mental health services? If YES, when did they last have contact with mental health services? Has the incident been reported in accorded with Department of Health guidance Independent investigation of adverse events in mental health services ** Is there any indication that this may be a Domestic Homicide? Key Points to Consider If YES, has the incident been managed in accordance with Home Office guidance Domestic Homicide Review - Statutory Guidance for the conduct of Domestic Homicide Reviews ** Are the Police involved? If YES, what actions have taken place? Has the alleged perpetrator been formally charged with an offence? Have individuals affected by this incident received appropriate post-incident support/debriefing? What is the current status of any legal proceedings? What is the outcome of the Court Case? verdict and sentence Is there a need to undertake an independent inquiry into the circumstances of this case? Have the lessons learnt from this incident been shared appropriately? **Further information contained in Appendix C Please note that a Homicide cannot be closed on STEIS until such time as: The decision is taken that an independent inquiry is not required OR The independent inquiry has been completed. Page 43 of 64

44 Hospital / Medical equipment failure - Key Questions - Prompt Card (PC19) What happened within the incident? establish timeline What was the actual piece of hospital or medical equipment that failed? Key Points to Consider If YES, what was the model, make and serial number and have the MHRA been informed? Have there been any national alerts issued in respect to this equipment? What arrangements were in place to ensure appropriate monitoring/ servicing/ recalibration of this Hospital / Medical equipment? Had this monitoring/ servicing/ recalibration been undertaken in accordance with the manufactures guidance? Was anyone injured as a direct result of this incident? If YES, who and what were the nature and extent of injuries? Has the injured individual been informed that there had been a Hospital / Medical equipment failure? If YES, what was their reaction? Is the incident RIDDOR reportable? Did this Hospital / Medical equipment failure lead to any delays in treatment or suspensions of service? If YES, what measures have been put into place to ensure service continuity? Has the organisation undertaken a check of all similar equipment to ensure that it is working effectively? Had staff involved in the incident received appropriate training in the use of the piece of Hospital / Medical equipment? What controls have been put into place post-incident to reduce the risks of reoccurrence? Has this incident identified any areas that need to be changed within policies/procedures/guidance? If YES, has these changes been embedded into practice? Have the lessons learnt from this incident been shared appropriately? Page 44 of 64

45 Maternity Incidents - Key Questions - Prompt Card (PC20) What was the nature of the incident Intrapartum death, Intrauterine death, Maternal Death, Maternal unplanned admission to ITU, Suspension of maternity services, Unexpected admission to NICU (neonatal intensive care unit) Unexpected neonatal death? What happened within the incident? establish timeline What happened to the Mother? / What happened to the Baby? What was the gestational age of the baby? Did the Mother and/or Baby have any known risk factors prior to the incident? What are the short term and long term implications of this incident? Was the incident a Never Event?** Key Points to Consider If appropriate, had the appropriate WHO Surgical Safety Checklist been used during this procedure?* Has the Mother/Family been informed of this incident? If YES, what was their reaction? Is there a Supervisory Investigation also taking place? If a Supervisory Investigation took place, what was the outcome? Has consideration been given to whether the practice of any individual has been found to be below agreed professional standards? Has this incident identified any areas that need to be changed within policies/procedures/guidance? If YES, has these changes been embedded into practice? Have any training issues with individuals been addressed? Have the lessons learnt from this incident been shared appropriately? Has post incident debriefing and support been offered? for staff/patient/family Was there appropriate staffing at the time of the incident? Had staff involved in the incident received appropriate training in the procedure they were performing in this incident? Had staff involved in the incident received appropriate training in the use of the equipment used in this incident? **Further information contained in Appendix C Page 45 of 64