Incident Reporting and Management

Transcription

1 Incident Reporting and Management POLICY NUMBER & CATEGORY RS 02 Risk &Safety VERSION NO & DATE 3 Feb 2014 RATIFYING COMMITTEE Clinical Governance Committee DATE RATIFIED July 2013 NEXT REVIEW DATE July 2016 EXECUTIVE DIRECTOR POLICY LEAD POLICY AUTHOR Director of Quality Improvement & Patient Experience Head of Governance Intelligence Head of Governance Intelligence FORMULATED VIA CONTEXT The requirements of this policy apply to all staff. An incident is any event which impacted adversely or had the potential to impact on the delivery of Trust Business. This will include any aspect of Trust business including patient care, staff wellbeing, systems, resources and public perception. POLICY All staff (permanent or temporary; qualified or unqualified of any discipline) must report incidents as defined in this policy. Details of how to report are set out in appendix 9. All incidents must be reported as soon as it is possible. All incidents will be reported in line with required external reporting arrangements and within defined timescales identified by external stakeholders / commissioners and national guidance. Staff are responsible to undertake any immediate action to make safe any situation or prevent further risk. Managers are required to review incidents in their area of responsibilities and ensure that appropriate actions have been taken to prevent recurrence or further risk. To ensure candour with respect to service users and carers, keeping them informed throughout the process. Page 1 of 50

2 Contents Page Number 1. Introduction Rationale Scope of the Policy Principles 3 2. Policy 3 3. Roles and responsibilities 4 4. Definition of an Untoward Incident 5 5. Reporting of Untoward Incidents 5 6. Reporting and Management of Serious Incidents 5 7. Informing Service Users 5 8. Duty of Candour 9. Management investigations Raising Concerns Complaints and claims Analysis of information Policy appendices Consultation Process Monitoring and audit Processes 7 Appendices 1. The definition of a Serious Incident Review Grade of Serious Incidents and Natural Cause Deaths External notification requirements Management of incidents Never events (Department of Health 2012/2013) Absconsion Questionnaire Information Governance Incident Grading 26 7a. Information Governance Questionnaire Serious Incident Reporting Requirements for Reporting Reporting incidents in accordance with the Reporting of Diseases and Dangerous Occurrences (RIDDOR) 1995 By-pass Notifications Reporting Process 11. Incident reporting process & procedure front page Process flowchart Eclipse guide to reporting an incident Eclipse guide to reporting a serious incident Eclipse incident management user guide Eclipse management of a serious incident Page 2 of 50

3 Introduction 1.1 Rationale (Why) The Trust is committed to ensuring that the care it provides is safe for all those being cared for and providing the care. Where incidents do occur it is vitally important that the Trust learns from these so as wherever possible prevent reoccurrence or otherwise reduce the risk The purpose of this policy is to ensure that internally There is a clear understanding of what an incident or near miss is. All staff understand their responsibility in reporting incidents and near misses involving staff, patients and others and how to report these. All managers understand their responsibility in managing incidents and near misses involving staff, patients and others. How to report an incident on Eclipse, the Trust Risk Management System, please see appendix 9. Who to contact when help is required with any of the former Additionally the purpose of this policy is to ensure that the Trust reports all incidents which meet the criteria for notification to external organisations as defined in appendix Scope of the Policy (when, where and who) This policy covers the reporting and immediate management of any incident in all Trust services. Where an incident classifies as a serious incident or requires further investigation this policy should be used in conjunction with the Trust Investigations (incorporating being open) Policy R&S All staff are required to ensure any incidents or near misses that they are directly involved in, witness or become aware of at any time are reported An incident is any event or circumstance arising that could have or did lead to unintended or unexpected harm, loss or damage to BSMHFT, commissioned services, patients, carers, visitors, staff, other members of the public, premises, property, other assets, information, or any other aspect of the organisation. Incidents come to light via the incident reporting system, complaints or claims process, PALS and provider organisations. They can involve any number of different factors, eg, injury, damage, loss, fire, theft, violence, abuse, accidents, ill health, non compliance with legal requirements, contract etc A Near Miss is an incident that did not lead to harm, loss or damage but had serious potential to do so, where lessons can be learnt to implement changes in procedures, processes and systems, for example a prevented clinical/patient safety incident. This can be explained by a premise if the harm did not reach the object. Object can be a patient, visitor, member of the public, staff, organisation, the service etc The policy takes account of the reporting protocols between the trust and external organisations such as HMP Birmingham. 1.3 Principles The purpose of incident reporting includes the following: To identify where an incident has occurred and communicate this to the appropriate manager and corporate teams so that appropriate local action can be taken. To identify trends, themes, recurrent risks, and key areas for learning thereby preventing reoccurrence and improving safety. To meet external reporting requirements as defined in appendix 3; Page 3 of 50

4 To enable the Trust Commissioners, NHS Protect, MHRA, and NHS Estates to satisfy the requirements of the Health and Safety at Work Act 1974 and national guidance. 2 Policy All incidents must be reported All incidents should be reported on Eclipse via the trust intranet. In areas where this is not currently possible a paper IR1 form/si fax notification should be completed and sent to the Governance Intelligence Team/ Eclipse@bsmhft.nhs.uk for entry All staff (permanent or temporary; qualified or unqualified of any discipline) must report incidents and near misses as defined in this policy. Details of how to report are set out in appendix Staff are also responsible to undertake any immediate action to make safe any situation or prevent further risk Managers are responsible for reviewing incidents reported in their area(s) of responsibility and ensuring that appropriate action(s) have been taken to prevent reoccurrence or further risk Managers should feedback actions and comments following an incident to the initial reporter of the incident using Eclipse Any incident should be reviewed in relation to risk and management action defined as appropriate and in line with the Trust Investigations policy The Head of Governance Intelligence is responsible for confirming whether an incident fulfils the criteria for a serious incident (SI) in alignment with appendix 1. If confirmed they will then be allocated to the appropriate review level The Head of Investigations is responsible for arbitration where a serious incident is disputed in relation to status or review level. 3 Roles and Responsibilities Post(s) All Staff Ward Managers / Team Managers Service, Clinical and Corporate Directors Head of Investigations Head of Governance Intelligence Responsibilities All staff (permanent or temporary; qualified or unqualified of any discipline) must report any incidents and near misses. Ward Managers / Team Managers have a responsibility for ensuring the accuracy of incident reports and determine / confirm that appropriate action been taken in response to the incident and to initiate any additional action as necessary. All have a responsibility to support staff and escalate reporting of the incident in line with risk criteria. Responsible for ensuring that all incidents are reported. Responsible for ensuring reports are appropriately escalated and are assured that immediate actions are taken to respond to incidents, support staff and service users / carers. Has responsibility for arbitration where there is dispute over a serious incident classification or allocated review grade. Responsible for reporting serious incidents to commissioners and entering/updating STEIS report. Responsible for initial confirmation of serious incidents and allocating initial review grade. Has responsibility for uploading patient safety incidents to the Page 4 of 50

5 Associate Director of Governance Director of Quality, Improvement and Patient Experience NRLS (NHS Commissioning Board Special Health Authority) and SIRS (NHS Protect) and providing incident data via pivot tables. Delegated responsibility for Risk Management. Updates to appendices identified in this policy may be approved by the Associate Director of Governance and reported at the next Clinical Governance committee. The Director of Quality, Improvement and Patient Experience (on behalf of the Chief Executive) is the Executive Director responsible for co-ordinating the management of clinical and non-clinical risk, which includes the reporting of untoward and serious incidents. 4 Definition of an Untoward Incident An untoward incident is any incident which meets the definition of an incident defined in section of this policy but which does not meet the criteria of a Serious Incident (SI) as defined in (appendix 1) Near misses, are defined in section of this policy. 5 Reporting of Untoward Incidents & Near Misses 5.1 An incident report should be completed by a member of staff who was involved in or who witnessed the incident wherever possible. Where there were no witnesses the staff member who identified that the incident occurred should report the incident. 5.2 All staff are responsible for any immediate action to ensure that any remaining risk is managed and no further harm is caused. These actions should be recorded on the eclipse incident form. 5.3 It is the Manager s responsibility to ensure that appropriate action has been taken to address the incident and check the factual accuracy of the completed sections of the eclipse form. Once the manager is satisfied with the above they are then required to make their comments and sign off as appropriate. This should be completed within 14 days of the incident being reported. 5.4 Where further information becomes available after signoff the manager should update the eclipse form and attach any relevant documents. 5.5 The Manager is also responsible for identifying whether or not the incident might be externally reportable as laid out in appendix 3. Notifiable to the Health & Safety Executive (HSE) under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR) (see R&S16 The Health & Safety Policy). Where a manager is unsure, advice can be sought from the Risk & Safety Team. 6 Reporting and Management of Serious Incidents (SIs) 6.1 Appendix 1 sets out the criteria for an incident being identified as a serious incident. 6.2 Incidents will be considered a SI in line with these criteria unless they can be demonstrated to be otherwise. Where further information becomes available providing this is entered on the Eclipse record, incidents may be downgraded to an untoward incident. 6.3 Where staff are unsure whether an incident meets the criteria for a SI they should discuss the incident with the Head of Governance Intelligence or the Head of Investigations. If this is not possible they should report the incident as a SI and it will be assessed against the SI criteria (appendix 1). Page 5 of 50

6 6.4 Managers should be familiar with these criteria and escalate the reporting of an incident as serious if they believe that it meets the criteria. 6.5 Where an incident, reported as an untoward incident, which meets the criteria for a SI, is identified it will be escalated within the Eclipse system by the Head of Governance Intelligence. The appropriate managers will be notified that the incident has been incorrectly reported and that the incident should now be managed as a SI. 6.6 The Head of Governance Intelligence will be responsible for confirming whether any incident is formally classified as a SI. Where the Head of Governance Intelligence requires assistance the Serious Incident Group (SIG) will be consulted to clarify if the incident meets the criteria for a SI. Where further information becomes available or arbitration is required the Head of Investigations will be responsible for reinforcing or determining that the SI should be downgraded. 6.7 Once an incident is identified as being a SI the Head of Governance Intelligence will assign an initial review grade. Where the Head of Governance Intelligence requires assistance the Serious Incident Group (SIG) will be consulted. The review grades are set out in appendix 2. The Head of Investigations is responsible for arbitration of the designated review level should it be disputed. 6.8 The Head of Investigations will be responsible for ensuring that any SI is reported on STEIS within 2 working days. 6.9 The Head of Investigations is responsible for notifying any other commissioners and external stakeholders which would not be informed through reporting on STEIS Never Events Appendix 5 sets out the Never events which are applicable to the Trust. These would initially be identified as Serious incidents and if they meet the never event criteria will be escalated by the Head of Governance Intelligence to the Associate Director of Governance The manager is responsible for completing the Serious Incident management report on Eclipse within 72 hours Where the SI is a grade B, C or D death the manager is also responsible for completing the Eclipse management questionnaire Deaths graded as an A are not a Serious Incident but require the manager to complete the Eclipse Serious Incident Management form and questionnaire within 14 days. 7 Informing / involving service users / carers 7.1 Being open when things go wrong is fundamental to the partnership between service users and those who provide their care. The Trust aims to establish an environment where service users/carers receive the information they need to enable them to understand what happened and the reassurance that everything possible will be done to ensure that a similar type of incident does not recur. 7.2 Service users who are directly involved in or affected by any incident/near miss must be informed promptly and given an open and transparent explanation as required. (see Investigations Policy incorporating Being Open) 7.3 For any incident confirmed as a serious incident Service users and carers will be kept informed of the review process by a nominated manager / clinician and involved at appropriate stages. These arrangements should be agreed with the service user or carer as part of initial contact following the incident. 7.4 Occasionally there may be an incident where it will be necessary to contact various service users i.e. if a member of staff has a notifiable disease and has contact with a large number of service users in the course of their work. These service users must also be contacted as a matter of course. Advice should be sought from a service Page 6 of 50

7 user s Consultant Psychiatrist and clinical team if there is concern or doubt about the information affecting a person s mental state. The Health Protection Agency will provide support and specialist advice in these cases (see Trust Infection Prevention & Control procedures). 8 Duty of Candour 8.1 All organisations must ensure they have systems and processes in place to enable the application of this duty. The key principles are: 8.2 This will apply to individual patient safety incidents which result in moderate harm, severe harm or death (using NPSA definitions) 8.3 The patient, family or carer would be informed that the incident had occurred within ten working days of it being reported to on Eclipse. This should be face to face where possible. 8.4 An apology should be provided where harm was caused. 8.5 A step-by-step explanation of what happened should be provided. This may be an initial view pending findings of an investigation. 8.6 Duty of candour is continued under the Investigations Policy R&S Management Investigations 10.1 All investigations will be conducted in accordance with the Trust s Investigation Policy incorporating Being Open principles. Where incidents require a management investigation please refer to the Investigation Policy R&S Raising Concerns 10.1 The Trust is committed to ensuring that all staff are open and honest and work in an environment of a fair and just culture. Staff can also refer to the Trust s Raising Concerns Policy for further guidance. The Trust will follow the principle that staff are positively supported who admit to being involved in incident or to making mistakes. Staff will be supported in reporting confidentially. Wherever appropriate, preventative action such as training will be undertaken, rather than disciplinary action In rare cases following a serious incident, operational managers may consider that there is a case for suspending staff or using the Trust disciplinary procedure the manager should use the NPSA decision making tool (see investigations policy) to consider the most appropriate action In some situations a member of staff may not feel comfortable reporting an incident which is sent to their manger. In these cases a staff member can use the by-pass notifications option on Eclipse (do not send to my manager). This process is shown in appendix 9 of this policy. 11 Complaints and Claims 11.1 Some incidents may lead to complaints and/or claims (ex-gratia, litigation). The information collected during the management of the incident will be used during the management of the complaint/claim. Incidents where a staff member is injured will be notified via eclipse to the claims department. All Serious Incidents will be notified to the Complaint Department on a weekly basis. Page 7 of 50

8 11.2 Conversely some complaints may describe an incident that has not been previously reported. The Governance Department should be notified of all formal complaints by the Complaints Department. 12 Analysis of Information 12.1 The routine reporting of incidents allows for trends and patterns to be identified through the analysis of the information. The Trust Clinical Governance Department will produce Division/Zone reports from pivot-tables every quarter to be presented at the local Clinical Governance Committees where the theme is safety. Key themes should be cascaded to teams by the senior/team managers where areas for action are identified The Trust Governance Department also provides quarterly incident analysis reports to the Clinical Governance Committee and Trust Board The Learning Lessons process will identify areas for themed analysis and where further more detailed analysis is required; this is part of the wider management of risk where incidents will also be reviewed in conjunction with complaints, claims and PALS concerns in order to identify weaknesses, patterns and themes and implications for practice Ad hoc reports will also be required on occasion to support particular initiatives or for particular Trust specialist officers, e.g. physical assaults on staff, service user falls, serious near misses and serious self harm. These reports will be provided by the Governance Department on request. 13 Policy appendices Updates to appendices identified in this policy may be approved by the Associate Director of Governance and reported at the next Clinical Governance committee. 14 Development & Consultation Process Date policy issued for consultation 24 May 2013 Number of versions produced for consultation 1 Committees / meetings where policy formally discussed Health & Safety Committee Date(s) 15 Monitoring and Audit Element to be monitored Lead Tool Freq Reporting Arrangements Reporting of incidents by all staff in all areas All untoward incidents must be signed off by the appropriate team manager within 14 days of the incident being reported. Head of Governance Intelligence Head of Governance Intelligence Incident report Overdue Signoff Report Acting on Recommenda tions and Lead(S) Change in Practice and Lessons to be shared Qtr CGC CD / SDM s As identified Week ly Team managers, SDMs & CDs SDM As identified Serious Incident Head of Open SI Week SDMs & CDs SDMs & CDs As identified Page 8 of 50

9 Management reports completed Governance Intelligence report ly Notification of STEIS within 2 working days Head of Governance Intelligence Safety Dashboa rd Mth CGC Investigations Team As identified Informing service users when an incident has occurred Head of Governance Intelligence Incident report Qtr CGC CD / SDMs As identified Duty of Candour Informing the patient and family when an incident has occurred Head of Governance Intelligence Incident report Qtr CGC CD / SDMs As identified NRLS reporting (including CQC notification via NRLS) Head of Governance Intelligence Organisa tion Patient Safety Incident Report Biannu ally CGC Head of Governance Intelligence As identified Deaths of detained patients Head of Compliance CQC report Qtr CGC CD / SDMs As identified External Reporting requirements: All external reporting is covered in appendix 3 For other than this policy all matters relating to compliance will be monitored through the primary policy as identified in appendix 3. Page 9 of 50

10 Appendix 1 Definition of a Serious Incident (SI) A serious incident is an incident that results in death or causes, or has potential to cause serious harm. Classification of Serious Incidents An incident that occurred in relation to NHS-funded services and care resulting in one of the following: o Unexpected or avoidable death of one or more o Patients currently in contact with Trust services Patients who have died within 6 months of being discharged from Trust services Staff visitors or members of the public RAID Service: Patient deaths from natural causes where the patient was only assessed by RAID, resulting in no further treatment, are not required to be reported as serious incidents, but must still be reported as untoward incidents on Eclipse. The incident report should clearly document what contact RAID had prior to the death. Where it is not clear the incident will be escalated to a serious incident and will require a minimum of an A grade review. Any death within an inpatient service area or patient of a residential care provider where this care is commissioned by the Trust. o Serious harm (typically depicted by admission to an acute hospital for treatment, where admission is a minimum of 24 hours) to one or more patients, staff, visitors or members of the public or where the outcome requires: o o o o life-saving intervention, major surgical/medical intervention, or will cause permanent harm shorten life expectancy result in prolonged pain including psychological harm (this includes incidents graded under the NPSA definition of severe harm); Perpetrator of a Homicide by a known service user; or a discharged service user where the discharge was less than 6 months prior to the date of the Homicide. Accidental or non-accidental injuries requiring hospitalisation or significant hospital treatment e.g. severe laceration or burns, fractures, multiple injuries and head injury leading to any loss of consciousness or concussion. Serious injuries as a result of deliberate self-harm or attempted suicide requiring hospitalisation or significant hospital treatment Escape / absconsion from a Medium Secure Facility (including failure to return from section 17 leave) o Absconsion (including failure to return from leave) of service users under section For all absconsions will require an absconsion questionnaire to be completed on Eclipse as part of the management signoff (appendix 6 ) Page 10 of 50

11 o A scenario that prevents or threatens to prevent a provider organisation s ability to continue to deliver healthcare services, for example, actual or potential loss of personal/organisational information, damage to property, reputation or the environment, or IT failure; o year old admission to an adult bed o Hostage or riot- Barricade situations on healthcare premises with or without the involvement of other staff or service users, visitors etc., where police intervention is required. Also to include hostage situations at other sites e.g. service users home, A&E Dept etc., where staff provide healthcare services and where police involvement is necessary o o o o Incident requiring evacuation, of patients, from a service area, e.g. fire, utility failure, bomb threat, Unplanned release of hazardous substances into the environment Fire - Any fire (including arson) that has led to significant property damage, harm to individuals, and that may also lead to disruption of a service e.g. temporary closure of a Ward. Information Governance incident scoring level 2 IG SIRI when assessed against the Department of Health Information Governance Matrix (see appendix 6) The Information Governance Lead should confirm the level. All information governance incidents (Levels 0, 1 and 2) will require an IG Questionnaire completed on Eclipse as part of the management signoff (appendix 6a). Serious threats or violent incident with a weapon by service user, staff member or a member of public, where there is a significant belief or likelihood that the individual will act upon the threat or use the weapon to cause serious harm. o Infection Control instance of MRSA Bacteraemia Colstridium difficile (related deaths only) Outbreaks of infection (Please refer to appendix 7 for more information) o Allegations of abuse, Allegations of abuse, which result in escalation through P.I.P.O.T. (Person in position of Trust) or L.A.D.O. (Local authority designated officer) where A staff member is identified as the alleged abuser of a patient The abuse is alleged to have occurred on whilst on Trust premises o Grade 3 or 4 pressure ulcer (excluding those occurring within 3 days of admission / transfer from other healthcare facility the transferring facility should be informed that the reporting responsibility lies with them in these instances) Ischaemic wounds in diabetic patients should not be confused with pressure ulcers. Contact the Tissue Viability Nurse for clarification if required. o One of the core set of Never Events (See Appendix 5) o HMP Birmingham - Deaths in Custody and Deaths within 7 days of discharge from HMP Birmingham Healthcare and Deaths occurring whilst on release under temporary licence (RUTL) from HM Prison Birmingham. Page 11 of 50

12 Review Grade of Serious Incidents and Natural Cause Deaths Appendix 2 Review Grade A B Review type When Timescale STEIS Reporta ble Death outside of service provision Internal review Death from -natural causes of a community patient with an open episode of Trust care -accidental eg. RTA -Homicide where the perpetrator is not associated with the Trust -Death of a patient where the duty if care is primarily that of another service eg. Nursing home, supported accommodation. SI as defined by criteria in appendix 1 which does not fall under other review grades (including data loss / information security incident (DH level 2, see appendix 6)) Example(s) 14 days No Community patient dies from pneumonia in acute hospital whilst under the care of CMHT. Community patient dies from cancer at home whilst under the care of AOT. Pressure Ulcer (3/4) 8 days Infection Control 20 days Other 6 weeks Yes In-patient found to have grade 3 pressure ulcer after 7 days of being admitted to ward. Discharged patient suspected to have commit suicide within 6 months of being referred back to the GP. Staff member sustaining fracture as a result of assault by a patient. Patient self-harms resulting in surgery. Unencrypted memory stick containing patient information is stolen from Trust premises. Absconsion of patient where they are involved in further incident whilst AWOL Page 12 of 50

13 C D E Death in custody (Prison) Inpatient review Internal enquiry As defined by Prison Commissioner in line with prison death custody arrangements In-patient deaths including patients in residential care commissioned by the Trust Homicides (perpetrator) Up to 6 months F Never Event All incidents meeting the definition for a never event (see appendix 5) G Internal SI Absconsions including failure to return from leave of sectioned patient (excluding forensic units & PICUs which are covered by B grade reviews) H Internal SI Any serious incident which does not meet the external reporting criteria or any other SI grade 6 weeks or as defined by Yes Prisoner commits suicide within 7 days of being released from prison. commissioners Prisoner dies of a heart attack whilst in HMP Prisoner on temporary license dies. 6 weeks Yes In-patient dies from natural causes whilst on ward. In-patient commits suicide whilst on leave from the ward. Death of a patient receiving care from a nursing home commissioned by the Trust Yes Patient with an open episode of care kills someone. Discharged patient kills a member of the public 5 months after being discharged from Trust services. 8 to 10 weeks Yes Death or severe harm as a result of a patient falling from an unrestricted window 6 weeks No Sectioned patient fails to return from unescorted leave and is not involved in further incident whilst AWOL 6 weeks No An incident which does not meet the external reporting criteria but is deemed to be a high risk or significant event Page 13 of 50

14 Appendix 3 External Notification Requirements Who to Notify When How Primary Trust Policy (monitoring & audit) HM Coroner Health & Safety Executive (HSE) Medicines and Healthcare Related Products Agency (MHRA) Sudden and/or unnatural deaths / deaths of inpatients Incidents notifiable under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) Suspected adverse reactions to medicines Direct telephone contact Online through HSE website - web form Through the Yellow Cards System R&S 02 Incident Reporting & Management R&S 16 Health & Safety C 06 Medicines Code By Who Doctor The Team/Ward Manager Clinicians / Healthcare workers Internal Notifications Legal Department Health & Safety Department Pharmacy Medicines and Healthcare Related Products Agency (MHRA) Birmingham City Council / Solihull City Council (Environmental Health) Incidents relating to medical devices under MHRA/2007/001 Confirmed reports of food poisoning Through MHRA website Direct telephone contact C 06 Medicines Code IC 01 Infection Prevention and Overarching Policy & IC 01 Annex H Outbreak of Infection Policy Clinicians / Healthcare workers Infection Control Team Health & Safety Department Associate Director of AHP s and Physical Health & Wellbeing Page 14 of 50

15 Public Health England (PHE) The recognition of a single case of infection with a novel or uncommon pathogen. All outbreaks and clusters of communicable diseases in the hospital (including periods of increased incidence for C. Difficile) Direct telephone contact IC 01 Infection Prevention and Overarching Policy & IC 01 Annex H Outbreak of Infection Policy Infection Control Team Associate Director of AHP s and Physical Health & Wellbeing Director of Quality, Improvement and Patient Experience NHS Estates Fire incidents Annually through ERIC system Care Quality Commission (CQC) Care Quality Commission (CQC) Absconsions from PICUs and Secure units where the patient has been detained under a hospital order. Deaths where the patient has been detained under a hospital order. Through CQC website Through CQC website R&S 15 Fire Safety C37 Missing Patient R&S 02 Incident Reporting & Management Health & Safety Officers / Fire Advisor Nurse in Charge / Ward Manager Nurse in Charge / Ward Manager Mental Health Act Administrators Mental Health Act Administrators Care Quality Commission (CQC) Certain deaths of people using the service Via National Reporting & Learning System (NRLS) R&S 02 Incident Reporting & Management Governance Intelligence Team Care Quality Commission (CQC) Allegations of abuse Via National Reporting & Learning System (NRLS) R&S 02 Incident Reporting & Management Governance Intelligence Team Safeguarding Team Page 15 of 50

16 Care Quality Commission (CQC) Events that stop or may stop the service running safely or properly Via National Reporting & Learning System (NRLS) R&S 02 Incident Reporting & Management Governance Intelligence Team Care Quality Commission (CQC) Serious injuries to people who use the activity Via National Reporting & Learning System (NRLS) R&S 02 Incident Reporting & Management Governance Intelligence Team National Confidential Enquiry into Suicide & Homicide Suicides or Homicides committed by a patient or discharged patient. Professor Louis Appleby PO Box 86, Manchester, M29 2EF CG 14 NICE Guidance and National Confidential Inquiries Medical Director / Assistant to the Medical Director NHS Protect Any incident of the following Bribery Corruption Criminal Damage Fraud Theft Violence, harassment, abuse and anti-social behaviour Through the Security Incident Reporting System (SIRS) R&S 02 Incident Reporting & Management Governance Intelligence Team Local Security Management Specialist (LSMS) NHS Commissioning Unintended or unexpected Through R&S 02 Governance Page 16 of 50

17 Board Special Health Authority (formerly NPSA) incident which could have, or did, lead to harm for one or more patients receiving NHS-funded healthcare. National Reporting and Learning System (NRLS) Incident Reporting & Management Intelligence Team Commissioning Groups - Birmingham CrossCity - WMSCT - NCG - BDAAT / SDAAT - SS Cluster Information Commissioner s Office (ICO) Via Connecting for Health Incidents that are identified as serious in alignment with the Trust Incident Reporting & management Policy All Information Governance incidents reported on Eclipse which meet a Level 2 final score Through the Strategic Executive Information System (STEIS) On the ICO Security breach notification form R&S 02 Incident Reporting & Management R&S 02 Incident Reporting & Management Investigations Team Information Governance Lead Page 17 of 50

18 Appendix 4 The Management of Incidents 1.1 Injuries The focus of managing an incident should always be to reduce risks of further harm, and reoccurrence. The following guidance sets out in further detail key issues which may be considered In the event of an injury to any person involved in Health and Social Care activities or on health and social care premises, the priority is to manage the situation safely and ensure that no further harm can occur Arrangements must then be made for the injured person to receive appropriate first aid/medical attention. If the injured person is a member of staff and the injury is minor, a First Aider should be contacted. If the injured person is a service user, a doctor should be contacted. In some circumstances, a crash call or a 999 emergency call may be required For Trust staff, certain injuries, such as inoculation incidents, bites and scratches must also be reported immediately via telephone to the Occupational Health Department, in accordance with the Inoculation Policy. If the injury occurs out of hours, the injured person must report to the nearest Accident & Emergency Department Non-Trust personnel incurring an injury should be strongly advised and assisted, if appropriate, to make an appointment to see their GP. If they are not registered with a GP, they should have assistance in attending the nearest Accident & Emergency Department Certain injuries are notifiable to the Health & Safety Executive. The Manager will inform the Health & Safety Executive under RIDDOR, using Form F2508 or by to the Incident Contact Centre. The Trust Risk Facilitator must also be advised.(see Appendix 8) In the event of a notifiable disease the HSE must be informed by using Form F2508a or by an to the Incident Contact Centre.(See Appendix 8) 1.2 Staff support If a member of staff is distressed following an incident, s/he should be offered support promptly. It may be appropriate for the individual to be sent home. The Service Development Manager must be advised of this action. Other individuals should also be offered support where appropriate When a serious incident occurs there is a need to ensure that support is offered promptly and provided to all staff involved Further support may be arranged, if required, for groups or individuals via Resolve Staff Care (see Trust Intranet contact details for Resolve The Coach House on ) Where an HM Coroner s inquest is to be held, the Trust s Legal Advisor will meet with staff called upon as witnesses, if required, to explain the procedures involved and the process of the HM Coroner s Court. 1.3 Investigations of incidents and potential disciplinary action Staff should refer to the Investigations Policy RS 03 Page 18 of 50

19 1.4 Police Involvement In certain circumstances, it may be necessary to notify the police of an incident, e.g. serious physical assault, service user absconsion, theft, deliberate fire setting, trespass or if a claim to the Criminal Injuries Compensation Authority may be made When a service user has committed an aggressive act, the clinical team needs to consider whether or not the police should be notified. In the event of actual physical assault all such cases must be reported to the Police (see Prevention & Management of Violence Policy). The Trust s Local Security Management Specialist (LSMS) should be notified of all cases involving assault to Trust staff and these will be reported to NHS Protect via SIRS (uploaded from Eclipse) The Trust s LSMS is in post to support staff who are victims of a physical assault and to monitor and support police investigations into such matters. Where a physical assault occurs, full details of the incident including police incident / crime number and the name or collar number and police station of the officer dealing with the matter should be passed to the LSMS as soon as is practicable. 1.5 Fire The Trust Fire Safety Policy and local Fire Procedures must be adhered to at all times, particularly in regard to calling the Fire Service and raising the alarm. Details of all fire setting incidents must be reported immediately to the Trust Risk & Safety Department. The Service development manager and the Head of Estates/Facilities Management must also be alerted (on-call arrangements apply out of hours) For more detail, staff can refer to the Fire Safety Policy. 1.6 Security In the event of a missing or absconded service user, the Missing Patients Policy must be followed The Trust s Local Security Management Specialist (LSMS) should be advised of serious security breaches as soon as is practicable depending on the seriousness of the incident and availability of the LSMS For further detail, staff can refer to the Security Management Policy In the event of an incident in which relates to the security of service user information, the Information Governance Lead must be informed who will then advise the Trust s Caldicott Guardian and where appropriate the Information Commissioner. 1.7 Infections & Notifiable Diseases Where an individual (staff or service user) contracts an infection or condition as a result of Trust activities, the Trust s Infection Control Nurse, Associate Director of AHP s and Physical Health & Wellbeing, Director of Quality, Improvement and Patient Experience must be informed In the event of an infectious outbreak, the Infection Control Nurse will notify the Health Protection Agency Certain conditions are notifiable to the Health & Safety Executive. In the event of a notifiable disease the HSE must be informed by using Form F2508a or by an to the Incident Contact Centre. Page 19 of 50

20 1.8 Untoward Incidents involving medical devices Estates and Facilities must also be notified and the Governance department should report to the MHRA (see Appendix 3). Page 20 of 50

21 Appendix 5 Never Events (Department of Health 2012/13) Never Events are defined by the Department of Health as serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented by healthcare providers. To be a Never Event, an incident must fulfil the following criteria; The incident has clear potential for or has caused severe harm/death. There is evidence of occurrence in the past (i.e. it is a known source of risk). There is existing national guidance and/or national safety recommendations on how the event can be prevented and support for implementation. The event is largely preventable if the guidance is implemented. Occurrence can be easily defined, identified and continually measured. Their occurrence is an indication that an organisation may have not put in place the right systems and processes to prevent the incidents from happening and thereby prevent harmful outcomes. It is also an indicator of how safe the organisation is and the patient safety culture within that setting. The list below are those Never Events that have been assessed as having potential for occurrence in BSMHFT. Each Never Event has an assigned lead in the Trust who has identified actions to prevent the occurrence of the Never Event. Maladministration of Insulin Death or severe harm as a result of maladministration of insulin by a health professional. Maladministration in this instance refers to when a health professional Uses any abbreviation for the words unit or units when prescribing insulin in writing, Issues an unclear or misinterpreted verbal instruction to a colleague, Fails to use a specific insulin administration device e.g. an insulin syringe or insulin pen to draw up or administer insulin, or Fails to give insulin when correctly prescribed. Setting: All healthcare settings. Overdose of midazolam during conscious sedation Death or severe harm as a result of overdose of midazolam injection following use of high strength midazolam (5mg/ml or 2mg/ml) for conscious sedation. Excludes areas where use of high strength midazolam is appropriate. These are specifically only in general anaesthesia, intensive care, palliative care, or where its use has been formally risk assessed. Excludes paediatric care. Setting: All healthcare premises. Suicide using non-collapsible rails Death or severe harm to a mental health inpatient as a result of a suicide attempt using noncollapsible curtain or shower rails. Setting: All mental health inpatient premises. Page 21 of 50

22 Entrapment in bedrails Death or severe harm as a result of entrapment of an adult in bedrails that do not comply with Medicines and Healthcare products Regulatory Agency (MHRA) dimensional guidance. Setting: All adult inpatient care premises. Inappropriate administration of daily oral methotrexate Prescription, supply or administration of daily oral methotrexate to a patient for non-cancer treatment including supply to the patient with the instruction to take daily. Excludes cancer treatment with daily oral methotrexate Excludes where the error is intercepted before the patient is supplied with the medication Setting: All healthcare settings. Opioid overdose of an opioid-naïve patient Death or severe harm as a result of an overdose of an opioid given to a patient who was opioid naïve. Specifically this means: Where a dose is used that is not consistent with the dosing protocol agreed by the healthcare organisation, or the manufacturer s recommended dosage for opioid-naïve patients*. Where the prescriber fails to ensure they were familiar with the therapeutic characteristics of the opioid prescribed. Excluded are cases where the patient was already receiving opioid medication Setting: All healthcare settings. Falls from unrestricted windows Death or severe harm as a result of a patient falling from an unrestricted window. Applies to windows within reach of patients. This means windows (including the window sill) that are within reach of someone standing at floor level and that can be exited/fallen from without needing to move furniture or use tools to assist in climbing out of the window. Includes windows located in facilities/areas where healthcare is provided and where patients can and do access. Includes where patients deliberately or accidentally fall from a window where a restrictor has been fitted but previously damaged or disabled, but does not include events where a patient deliberately disables a restrictor or breaks the window immediately before the fall. Setting: All healthcare premises. Severe scalding of patients Death or severe harm as a result of a patient being scalded by water used for washing/bathing. Excludes scalds from water being used for purposes other than washing/bathing (eg from kettles) Setting: All healthcare premises. Misplaced naso- or oro-gastric tubes Death or severe harm as a result of a naso- or oro-gastric tube being misplaced in the respiratory tract. Page 22 of 50

23 Setting: All healthcare premises. Wrong gas administered Death or severe harm as a result of the administration of the wrong gas, or failure to administer any gas, through a line designated for Medical Gas Pipeline Systems (MGPS) or through a line connected directly to a portable gas cylinder. Setting: All healthcare premises. Failure to monitor and respond to oxygen saturation Death or severe harm as a result of failure to monitor or respond to oxygen saturation levels in a patient undergoing general or regional anaesthesia, or conscious sedation for a healthcare procedure (e.g. endoscopy). Includes failure to physically have monitoring in place, and failure to act on relevant information from monitoring oxygen saturation. Excludes where action is taken in response to recorded adverse oxygen saturation levels, but this fails to prevent death or severe harm for other reasons (e.g. preexisting problems with oxygenation that cannot be resolved). Excludes incidents where the accepted limitations of monitoring equipment mean that adverse readings may be artefactual (e.g. shock/vasoconstriction). Settings: All healthcare premises Escape of a transferred prisoner A patient who is a transferred prisoner escaping from medium or high secure mental health services where they have been placed for treatment subject to Ministry of Justice restriction directions. Setting: All medium and high secure mental health inpatient premises Page 23 of 50

24 ***Please note this should be completed on Eclipse*** Appendix 6 Have there been similar absconding incidents from this ward / unit? If YES, had the previous root causes been adequately addressed and any changes embedded into practice? What was the patient s MHA status at the time of the absconsion? Was the patient known to be an absconding risk before this incident? If YES, did they have an appropriate care plan in place? Have there been any previous absconsion incidents reported for this service user? 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 Trust policy? 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? In the preceding 24 hours to the absconsion what organised activities took place on the ward? Did the service user take part in any of these activities? Did this incident take place at a known high risk time e.g. shift handover, mealtime, drug round etc.,? Was the Missing Patient Policy utilised effectively within this incident? Were the appropriate individuals notified Absconsion Questionnaire Page 24 of 50

25 that the patient had gone missing? Were the police notified? Had clinical staff received relevant training in respect to reducing the risks of absconsion? Did the patient return? How did the patient return? Was the patient physically examined? Did the patient suffer any injury (including self harm) whilst AWOL? Has the patient been asked why they absconded? (detail feedback) Was the level of observation increased when the patient returned? Was the patient assessed prior to going on leave, for the risk of failure to return? Was this assessment documented / recorded? Page 25 of 50

26 Appendix 7 Information Governance Serious Incidents (IGSIs) Information Governance incidents that fulfil the criteria of being an SI must be handled in accordance with the Department of Health s Checklist Guidance for Reporting, Managing and Investigating Information Governance Serious Incidents Requiring Investigation June This guidance can be accessed at %20Guidance%20V2%200%201st%20June% pdf The IG SIRI category is determined by the context, scale and sensitivity. Every incident can be categorised as: Level 1 = Confirmed IG SIRI but no need to report to ICO, DH and other central bodies Level 2 = Confirmed IG SIRI that must be reported to ICO, DH and other central bodies A further category of IG SIRI is also possible and should be used in incident closure. This is where it is determined that it was a near miss or the incident is found to have been mistakenly reported. Such cases should be immediately highlighted to the CCG so that they can be removed from STEIS. In respect to all IGSIs the following process should be followed to categorise the incident: Step 1: Establish the scale of the incident. If this is not known it will be necessary to estimate the maximum potential scale point. Baseline Score 0 Information about less than 10 individuals 1 Information about individuals 1 Information about individuals 2 Information about individuals 2 Information about individuals 2 Information about 501 1,000 individuals 3 Information about 1,001 5,000 individuals 3 Information about 5,001 10,000 individuals 3 Information about 10, ,000 individuals 3 Information about 100,001 + individuals Step 2: Identify which sensitivity characteristics may apply and the baseline scale point will adjust accordingly. Page 26 of 50

27 Sensitivity Factors (SF) modify baseline scale Low: For each of the following factors reduce the baseline score by 1 No clinical data at risk -1 for each Limited demographic data at risk e.g. address not included, name not included Security controls/difficulty to access data partially mitigates risk Medium: The following factors have no effect on baseline score 0 Basic demographic data at risk e.g. equivalent to telephone directory Limited clinical information at risk e.g. clinic attendance, ward handover sheet High: For each of the following factors increase the baseline score by 1 Detailed clinical information at risk e.g. case notes Particularly sensitive information at risk e.g. HIV, STD, Mental Health, Children One or more previous incidents of a similar type in past 12 months Failure to securely encrypt mobile technology or other obvious security failing +1 for each Celebrity involved or other newsworthy aspects or media interest A complaint has been made to the Information Commissioner Individuals affected are likely to suffer significant distress or embarrassment Individuals affected have been placed at risk of physical harm Individuals affected may suffer significant detriment e.g. financial loss Incident has incurred or risked incurring a clinical untoward incident Step 3: Where adjusted scale indicates that the incident is level 2, the incident will be reported to the ICO and DH automatically via the IG Incident Reporting Tool. Final Score Level of SIRI 1 or less Level 1 IG SIRI (Not Reportable) 2 or more Level 2 IG SIRI (Reportable) Page 27 of 50

28 INFORMATION GOVERNANCE INCIDENT: Appendix 7a Incident details: Reported by QUESTIONS: What type of personal data was involved- staff or client? How sensitive was the data? Low: no clinical data/ no name or address Medium: low level clinical data or basic demographic data High: Detailed clinical data/ sensitive staff data/ individuals have been put at risk of harm/ risk of fraud List the data items affected. E.g. name, pay scale, age, post code, diagnosis etc Number of data subjects impacted by this breach (how many staff or clients?): If personal data has been passed inappropriately to another define who this is: a) Another NHS b) A public sector organisation (non NHS) c) Any other organisation d) Individual members of public e) Not known What format of information was involved paper, electronic, other? If electronic state what, e.g. , memory stick. Does the loss of this information potentially impact on any of the data subjects? E.g. could staff information be used fraudulently, could clients be at risk? How has the information been lost, sent to the wrong person, sent insecurely, too much information sent? Has the information been returned/ found? (if applicable) What immediate action was taken after the incident to mitigate any risk? Was the incident caused by an action not compliant with policy and/ or procedure Have the data subjects been informed? If not, why not? Is the person who caused the incident compliant with their IG training? 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, describe and have these changes been embedded into practice? Any other useful information? Page 28 of 50

29 Appendix 8 Serious Incident Reporting Requirements for Reporting Clostridium difficile, MRSA bacteraemia and other HCAI Outbreaks or Incidents Incident MRSA bacteraemia Clostridium difficile related deaths Clostridium difficile Periods of increased incidence (PII) Outbreaks of infection Deaths attributed to a healthcare associated infection (HCAI) Specific guidance All cases Deaths where Clostridium difficile is recoded in part 1 (a, b, or c) of the death certificate only All incidents regardless of bed closures All outbreaks regardless of bed closures Any death where a HCAI is listed on Part 1a of the death certificate only. Comments o Regardless of where acquired or the source of infection. o Includes contaminated specimens. o CCG should make clear the process by which the incident is reported dependant on pre/post 48 hour cases and contaminants. o CCG must ensure that there is robust reporting in place and all cases are captured. This includes deaths in the community were C. diff is on part 1 of the death certificate. o Period of increased incidence is defined as 2 or more new cases (occurring more than 48 hours after admission, not relapses) in a 28 day period on a ward. o PII may occur in the community linked to prescriber s practices or in a care situation. Again more than 2 cases in a 28 day period linked by time, place or person must be reported. An outbreak is an incident which meets any of the following criteria: o An incident in which two or more people experiencing a similar infectious illness are linked in time/place; o A greater than expected rate of infection compared with the usual background rate for the place and time where the outbreak has occurred; o A single case for certain rare diseases such as diphtheria, botulism, rabies, viral haemorrhagic fever, legionnaire s disease or polio (NB: this list is not exhaustive). o CCG s will need to identify methods of consistently collating this data. o Through this process avoidable deaths should be identified and the risk of repetition of the incident reduced. NB: Deaths due to Clostridium difficile infection should be reported as specified. Grading of Incident Grade 1 (Serious Incident). Grade 1 (Serious Incident). Grade 0 (Notification only). Grade 1 (Serious Incident). Grade 1 (Serious Incident). Page 29 of 50

30 Appendix 9 Reporting Incidents in accordance with the Reporting of Diseases Dangerous Occurrences Regulations (RIDDOR) RIDDOR Explained RIDDOR stands for Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (1995). These regulations govern accident reporting for employers, self employed people and people in control of premises. A RIDDOR report is required to be made for any significant injury over seven days leading to incapacitation. (Not counting the day on which the accident happened). Incapacitation means that the worker is absent or unable to do work that they would have reasonably be expected to do as part of their normal work. Employers must still keep a record of all three day injuries (incident reports suffice for this) The deadline for reporting over 7 day injuries has increased to15 days from the day of the accident / incident. RIDDOR places a duty on organisations to report work-related deaths, major injuries, over seven-day-injuries, work related diseases and dangerous occurrences (near miss accidents). The information which we supply to RIDDOR enables the Health and Safety Executive (HSE) and local authorities to identify how and why risk occurs and if necessary to investigate serious accidents. RIDDOR can also help to provide advice on how to make the workplace a safer environment and on how to reduce injury and ill health in the workplace. 2. What is reportable under RIDDOR? As an employer, a person who is self-employed, or someone in control of work premises, you have legal duties under RIDDOR that require you to report and record some work-related accidents by the quickest means possible. Reportable issues are: 2.1 Death 2.2 Major Injuries 2.3 Over 7 day injuries 2.4 Taken to hospital as a result of an accident 2.5 Diseases 2.6 Dangerous Occurrences 2.1 Deaths If there is an accident connected with work and your employee, or selfemployed person working on the premises, or a member of the public is killed you must notify the enforcing authority without delay. You can either telephone the Incident Contact Centre on or complete the form F2508 also available via the HSE web site Page 30 of 50

31 2.2 Major injuries If there is an accident connected with work and your employee, or selfemployed person working on the premises sustains a major injury, or a member of the public suffers an injury and is taken to hospital from the site of the accident, you must notify the enforcing authority without delay by telephoning the Incident Contact Centre on or complete the form F2508 also available via the HSE web site Reportable Major Injuries are: fracture, other than to fingers, thumbs and toes; amputation; dislocation of the shoulder, hip, knee or spine; loss of sight (temporary or permanent); chemical or hot metal burn to the eye or any penetrating injury to the eye; injury resulting from an electric shock or electrical burn leading to unconsciousness, or requiring resuscitation or admittance to hospital for more than 24 hours; any other injury: leading to hypothermia, heat-induced illness or unconsciousness; or requiring resuscitation; or requiring admittance to hospital for more than 24 hours; unconsciousness caused by asphyxia or exposure to harmful substance or biological agent; acute illness requiring medical treatment, or loss of consciousness arising from absorption of any substance by inhalation, ingestion or through the skin; acute illness requiring medical treatment where there is reason to believe that this resulted from exposure to a biological agent or its toxins or infected material. 2.3 Reportable over-seven-day injuries If there is an accident connected with work (including an act of physical violence) and your employee, or a self-employed person working on your premises, suffers an over-seven-day injury you must report it to the enforcing authority within fifteen days. An over-7-day injury is one which is not major but results in the injured person being away from work or, unable to do their full range of their normal duties for more than seven days. You can notify the enforcing authority by telephoning the Incident Contact Centre on or complete the form F2508 also available via the HSE web site Reportable disease If a doctor notifies you that your employee suffers from a reportable workrelated disease, then you must report it to the enforcing authority. Reportable diseases include: certain poisonings; some skin diseases such as occupational dermatitis, skin cancer, chrome ulcer, oil folliculitis/acne; lung diseases including: occupational asthma, farmer's lung, pneumoconiosis, asbestosis, mesothelioma; Page 31 of 50

32 infections such as: leptospirosis; hepatitis; tuberculosis; anthrax; legionellosis and tetanus; other conditions such as: occupational cancer; certain musculoskeletal disorders; decompression illness and hand-arm vibration syndrome. A full list of reportable disease is available via the HSE web site You can notify the enforcing authority by telephoning the Incident Contact Centre on or completing the form F2508A also available via the HSE web site Reportable dangerous occurrences (near misses) If something happens which does not result in a reportable injury, but which clearly could have done, then it may be a dangerous occurrence which must be reported immediately. Call the Incident Contact Centre on or complete the form F2508 also available via the HSE web site Reportable dangerous occurrences are: collapse, overturning or failure of load-bearing parts of lifts and lifting equipment; explosion, collapse or bursting of any closed vessel or associated pipe-work; failure of any freight container in any of its load-bearing parts; plant or equipment coming into contact with overhead power lines; electrical short circuit or overload causing fire or explosion; any unintentional explosion, misfire, failure of demolition to cause the intended collapse, projection of material beyond a site boundary, injury caused by an explosion; Accidental release of a biological agent likely to cause severe human illness; failure of industrial radiography or irradiation equipment to de-energise or return to its safe position after the intended exposure period; malfunction of breathing apparatus while in use or during testing immediately before use; failure or endangering of diving equipment, the trapping of a diver, an explosion near a diver, or an uncontrolled ascent; collapse or partial collapse of a scaffold over five metres high, or erected near water where there could be a risk of drowning after a fall; unintended collision of a train with any vehicle; dangerous occurrence at a well (other than a water well); dangerous occurrence at a pipeline; failure of any load-bearing fairground equipment, or derailment or unintended collision of cars or trains; a road tanker carrying a dangerous substance overturns, suffers serious damage, catches fire or the substance is released; a dangerous substance being conveyed by road is involved in a fire or released; the following dangerous occurrences are reportable except in relation to offshore workplaces: unintended collapse of: any building or structure under construction, alteration or demolition where over five tonnes of material falls; a wall or floor in a place of work; any false-work; Page 32 of 50

33 explosion or fire causing suspension of normal work for over 24 hours; sudden, uncontrolled release in a building of: 100 kg or more of flammable liquid; 10 kg of flammable liquid above its boiling point; 10 kg or more of flammable gas; or of 500 kg of these substances if the release is in the open air; accidental release of any substance which may damage health. 3. Trust Approach The Trust is required to perform their duties in accordance with the Health and Safety at Work etc Act 1974 and other associated/relevant Legislation including the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR). It is the responsibility of employees to report all incidents, injuries, diseases and dangerous occurrences to their manager as quickly as possible. A copy of RIDDOR reports MUST be sent to the Trust Health and Safety advisor. Page 33 of 50

34 Eclipse Incident By-pass Notification Process Appendix 10 Incident reported using bypass notifications on Eclipse Incident Flagged up as BLUE in web holding by GITeam Incident checked by Head of Governance Intelligence who will check if there is any significant reason for bypassing notifications Concern identified Concern unclear Incident forwarded to relevant Associate Director of Operations for review/action through Eclipse Does this meet the criteria for a Serious Incident? Yes No Reporter contacted to seek clarification for bypass Confirmed as deliberate intention Confirmed as reporter error GITeam attach evidence to incident and reactivate notification loops on Eclipse Reported as a Serious Incident by ADO on Eclipse with no reference to original incident Incidents investigated / reviewed and signed off on Eclipse by ADO Incident resumes usual pathway on Eclipse Incident managed as a Serious Incident on Eclipse Incident Closed on Eclipse but remains flagged Page 34 of 50

35 Appendix 11 Incident reporting process and procedure guidance page Process flowchart 31 Guide to reporting an Incident on Eclipse 32 Reporting Serious Incidents on Eclipse 34 Eclipse Incident management user guide 35 Serious Incident management guide on Eclipse 43 Page 35 of 50

36 Category A death from natural causes deadline for manager sign-off Categories B C D & E deadline for manager signoff Does the incident meet SI criteria? YES NO Eclipse SERIOUS Incident form completed Eclipse Incident form completed 24 Hrs Manager, CD, SDM automatically notified Manager automatically notified via Eclipse Manager completes Eclipse Serious Incident management form 72 Hrs Is this a patient death? YES NO Eclipse Serious Incident management questionnaire completed Eclipse management Form 3 completed by SDM Manager completes Eclipse manager s form 14 days RCA/External Review Page 36 of 50

37 Guide to Reporting an Incident on Eclipse Once you have logged into Eclipse you will see the home screen as displayed below. Firstly you must decide what type of incident you are reporting. Untoward incident: any event, which has given or may give rise to actual or possible personal injury, to service user dissatisfaction or to property loss or damage. This definition covers service user/ staff/ visitor/contractor injury, fire, theft, assault, security issues, verbal abuse and harassment, racial and sexual abuse, and accidents. To access the appropriate incident form you must then click on either the incident or serious incident button. Serious incident: an untoward incident that results in death or causes, or has potential to cause, such serious harm that it may place life in jeopardy. These incidents are managed under The Management of Serious Untoward Incidents Policy. This also includes a serious near miss. Page 37 of 50

38 All yellow boxes must be completed If left empty you will be unable to submit the incident report Automatically completed details ~ if any are inaccurate please eclipse@bsmhft.nhs.uk with the relevant changes What happened and when? This section of the form is used to capture the core incident details However NO patient, staff or visitor identifiable information should be used within this section. You should refer to people involved by their role or job title only eg: patient was verbally abusive to HCA and repeatedly threatened physical assault. Additional details used to capture action taken immediately following the incident Within which team did the incident occur? What was the specific location of the incident? All persons involved should be recorded here, this includes Victim, aggressor, witness, assessing doctor All medication errors must capture which drug was involved Police involvement must be stated and the crime number reported You can add attachments here ~ any documents you would have stapled to the paper IR1 form can be added here Save and finish incident later Submit incident Manager receives incident Page 38 of 50

39 Need Help? Reporting of Serious incidents on Eclipse Serious incidents should be reported directly on to eclipse, and NOT via S.I. Fax Notification to the S.I. Inbox/Risk Department. This guide will help you report your serious incident on the eclipse system. To report a serious incident, click on the serious incident form button, on the top left hand side of the eclipse home page. The serious incident form will now load; this will have the following header. Simply complete the form as you would for any incident, remembering to do the following: 1. Tick the SI tick box 2. Complete all yellow boxes (these are mandatory fields) 3. Add all people involved 4. Add any injuries When you have completed the form and pressed the submit button a questionnaire will appear (called SI Fax Notification). Simply tick any boxes which are applicable. When you have completed this press save (located in the bottom right hand corner). A Save Questionnaire box will appear. PLEASE NOTE If you tick the please confirm that you have completed this questionnaire box You will NOT be able to edit the questionnaire at a later date. NOTIFICATIONS All incidents reported on the Eclipse Serious Incident form will go directly to the S.I. inbox & the team manager whose team the incident is associated with. Page 39 of 50

40 Need Help? Eclipse Incident Management User Guide Page 40 of 50

41 Need Help? 1. The Web incident process To enter an incident click on either <Incident> or <Serious Incident> option on the web home page. When an incident is submitted, notification s are sent to the relevant staff, based on the Notification Rules set up in Eclipse Risk Management system. These Incidents Eclipse Web system under <Manage Incidents> for the appropriate user(s). 2. Manage Incidents To retrieve your Incidents in the Eclipse Web system, log in and click on <Manage Incidents>. 2.1 Incident List Incidents will be listed in three different colours: Green Incidents are those for which you received an notification Yellow Incidents are those entered by you but not completed at the time of entry ie. Save for Later Blue Incidents are those for which you are either: - responsible for completing an Action, but you did not receive an notification. Therefore you do not have access to the Managers Form. - Started to complete a questionnaire, but did not tick the completed box on saving. Therefore the Questionnaire needs to be completed. Page 41 of 50

42 Need Help? Alert Column (Used to highlight Serious Incidents) The Alert symbol is entered on the records through the windows system. The different colours of the alert have different meanings, and the user should <right click> over the symbol to show the meaning. This functionality can be used by the risk department to draw attention to a specific incident within the list. Click on the column heading to order by the Alert flag. Questionnaire The Questionnaire column has Q as the title. The Questionnaire icon with a tick through it means that the inputter has completed the questionnaire. To view the questionnaire, click on the Questionnaire icon and the information is shown in the panel to the right. Feedback Flags The Feedback column has FBack as the title. Feedback about the incident can be sent back to the incident reporter by and it is indicated in this column. The Feedback is a specific field on the Incident page, located in the Outcome section, and should be completed by managers. There is a specific check box field that should be ticked for the system to feedback to the reporter. Managers can prioritise Incidents within their lists in a similar way to Microsoft Outlook. The flags are set within the maintenance tables, <shared files><web Flags>. By default, the descriptions for the flags are the colours, but these descriptions can be changed. To order the list by the flag, click on the field title. Tooltips indicate the meaning of the flag. Contact the system supervisor to discuss setting up these flags. Click on the column heading to order by the incident flag. Sorting Columns The following columns may be sorted: Alert, Number, Cause, Date, Status, Flag. Page 42 of 50

43 Need Help? Incident Number Search Enter the required incident number and click on the magnifier to search. Filter List The filter icon, next to the magnifier shows the selections available. By default the system shows the incidents that have a status of open for the manager logged in (section section explaining Incident Status) Incident Summary - Open Incidents is the default, a list of ongoing incidents for the member of staff logged in - Closed Incidents are those incidents that the manager was dealing with but their part is not complete - Closed Actions are those incidents where the manager was completing an individual action for the incident. Use a left click on an incident to view a summary of the incident on the right side of the page. Page 43 of 50

44 Need Help? 2.3. Managers Form The managers incident page or <Managers Form> will display the original incident report form with the details entered by the reporter (in read only format). It will also include additional sections for the manager to complete such as <Managers Comments>, <Outcome & Feedback>, <Recommendations>, <Final Grading> and <Further Action> allowing them to enter details from actions completed during the investigation process. To access this form, highlight the appropriate incident record on the left of the window to open incident summary page. Click on the <Managers Form> button to open the managers incident page. Complete the details as necessary and click on the <Save and Continue> button if further details are to be entered at a later date, or <Save and Close>. Note these two buttons at the bottom of your form may read different as the words are configured by your organisation. When <Save and Close> is selected, the status of the incident will then change to Completed and it will automatically be removed from your list. Page 44 of 50

45 Need Help? 2.4. Clear Incidents When an incident is complete, ie no further action is required and the managers incident form has been submitted, it can be cleared from the list of incidents. To do this, highlight the incident to open the summary page and click on the <Clear from List> button. This Clear from List should also be used if the incident is being dealt with by another manager and you want to remove it from your list. The system will display a message similar to the one shown below. Click on <Yes> to proceed. 3. Notification & Status 3.1. Notification list Click on the <Notification & Status> tab to view the names of other staff notified of the incident. Page 45 of 50

46 Need Help? 3.2. Add Notify If required, more staff members can be added to the list and notified about the incident. To do this click on the <Add Notify> button. This will open a new Form Person to Notify This is a member of staff from the Eclipse staff list. Type in surname and first name and the list appears showing the address. Text Information entered into the Text field is shown in the body of the , for example I am forwarding this Incident to you because. This information is saved within Eclipse under the correspondence section (in the web holding file). Therefore although the text is not viewable through the system, it is recorded and can be read by the Risk Management Department. Click on the <Notify> button when the fields have been completed Return to Reporter Page 46 of 50

47 Need Help? Text Information entered into the Text field is shown in the body of the , for example I am returning this Incident to you because. This information is saved within Eclipse under the correspondence section (in the web holding file). Therefore although the text is not viewable through the system, it is recorded and can be read by the Risk Management Department. Click on the <Return> button when the fields have been completed. 4. Incident & Manager Status 4.1. Incident Status An Incident has a Status and this status is changed automatically as it goes through the process: When an Incident is entered but entry is not finished it is Saved for Later When an Incident is entered and managers are notified, it is Waiting for Managers Form When a Manager has opened the Manager s form and used <Save and Continue>, it is Under Review When a Manager has opened the Manager s form and used <Save and Close>, it is Completed When a Manager has returned the Incident to the reporter for more information, it is Returned to Reporter. Note that these words may be different in your system as they can be changed by the system supervisor Manager Status The Managers notified about the Incident have a status so that people involved can see where each other are in the process and who has looked at it. This is recorded in the Notification list in both the Web and Windows systems: When a Manager has opened the Manager s form and used <Save and Continue>, their status is Under Review When a Manager has opened the Manager s form and used <Save and Close>, their status Completed When a Manager clears the Incident from their list using the <Clear from list> button, their status is Read and Cleared When a Manager has returned the Incident to the reporter for more information, their status is Returned to Reporter Page 47 of 50

48 Need Help? Management of Serious incidents on Eclipse Serious incident management reports should be reported directly on to eclipse, and NOT via the SI Inbox/Risk Department. This guide will help you complete your serious incident management report on the eclipse system. When a member of your team reports a serious incident on eclipse you as the manager will receive an message which is a brief summary of the incident. Within 72 hours you should logon to eclipse and complete the management report. The exception is a natural cause death (community patient only) in which case the management report should be completed within 14 days. Once you have logged in click on manage incidents at the top of the home page This will take you into the screen shown below. By clicking on the incident from the list on the left a brief summary of the incident will be displayed on the right. PLEASE NOTE If an incident is marked with a purple triangle it is an open SI yellow triangle it was reported as an SI but has been downgraded orange triangle it is awaiting approval by the Serious Incident Group (SIG) green triangle it is a closed SI Click on the button managers form to open the management report for the incident. Page 48 of 50

49 Need Help? Simply complete the form as you would for any incident, remembering to do the following: 5. Complete all yellow boxes (these are mandatory fields) 6. Add any missing people involved 7. Add any injuries not stated when reported When you have completed the management form you should pressed the signoff button at the bottom of the incident. PLEASE NOTE Patient Death If you are completing the management report for a patient death you must complete the SI Category A Management Questionnaire Once this questionnaire has been completed, the SI management report is now fully completed. The SI Category A Management Questionnaire should appear when you press the management report signoff button. In the event that this does not occur please follow the steps below to access the questionnaire. Click on the incident you would like to add a questionnaire to. When the summary appears on the right hand side of the screen, click on the questionnaire tab. Click on the Add Questionnaire button and a Questionnaire box will appear. Select S.I. Category A Management from the drop down list, then click save. Page 49 of 50

50 Need Help? The S.I. Category A Management questionnaire will now appear within the incident questionnaire tab section. Click on the questionnaire and this will open the questionnaire ready for you to complete. Complete the questionnaire and click save at the bottom. A Save Questionnaire box will appear press Save. WARNING If you tick the please confirm that you have completed this questionnaire box You will NOT be able to edit the questionnaire at a later date. You have now successfully completed the Serious Incident management report for a patient death Page 50 of 50