SERIOUS PATIENT SAFETY INCIDENT REPORTING

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1 SERIOUS PATIENT SAFETY INCIDENT REPORTING Executive Lead : Director of Nursing Author Patient Safety Manager, Caring for People, Keeping People Well : This report underpins the Health Board s Sustainability elements of the Health Board s Strategy. Financial impact : There are significant potential financial implications associated with this work in relation to clinical negligence claims. Quality, Safety, Patient Experience impact : The work outlined within this paper reflects the significant activity taking place to improve patient safety and experience leading to improved quality and care outcomes for patients. Health and Care Standard Number: 2.1, 3.1, 3.3 CRAF Reference Number: 5.1, 5.1.5, 5.6, 5.7 Equality Impact Assessment Completed: Not Applicable RECOMMENDATION The Board is asked to: CONSIDER the Serious Patient Safety Incident report. SITUATION The Board received a report on serious patient safety incidents reported by Cardiff and Vale UHB to Welsh Government (WG), at its meeting on 5 th May This report provides the Board with an update on the number and themes of Serious Incidents (SI) and No Surprises/Sensitive Issues (NS) reported to Welsh Government since the position provided in May BACKGROUND The Health Board is required to report Serious Incidents (SI) relating to patient safety and No Surprises (NS), through an agreed internal process, to Welsh Government as outlined within guidance issued in July This guidance was updated in April 2011, and more recently in February 2014, to reflect the revised regulations relating to Putting Things Right. For ease of reference, a Serious Incident (SI) is defined as an event that occurred during NHS funded healthcare (including in the community setting) which resulted in unexpected or avoidable death or severe harm of one or more patients, staff or members of the public; was a Never Event, threatens to prevent an organization s ability to continue to deliver healthcare services, allegations of physical/sexual abuse or adverse media attention about an organization.

2 No Surprises reporting requires Health Boards/Trusts to report sensitive issues to Welsh Government. Such issues may include incidents or events which could lead to adverse media attention, temporary capacity issues or incidents where it is initially unclear whether a serious incident has occurred. Patient safety incidents reported through the UHB Risk Management System (DATIX) are uploaded anonymously to the National Reporting and Learning System (NRLS). The UHB usually reports in the region of 15,000 patient safety related incidents to the NRLS annually, the vast majority of which fall within the near miss, no harm and low harm categories. This is set in the context of approximately 1.8 million patient contacts which represents less than 1% of patient related activity occurring within the UHB. It should be noted that whilst the UHB is in transition to implement an electronic incident reporting mechanism, there has been some disruption to the NRLS upload process. The Patient Safety Team successfully uploaded a large volume of patient safety incidents to the NRLS by the required deadline in May 2015 for incidents that occurred between 1 st October 2014 and 31 st March Work is now underway to ensure that data upload processes are streamlined in order to upload incidents more promptly to the NRLS as electronic incident reporting embeds within the UHB so that the time between the incident date and submission to the NRLS significantly reduces over the coming months. In order to protect patient / family confidentiality, the detail of each individual incident is discussed and taken forward within the relevant Clinical Board as appropriate and summary information is provided within this report only. When appropriate, the outcome of any internal review is shared with the patient and/or their family and with HM Coroner or other external body when the UHB is required to do so. ASSESSMENT Since the May 2015 Board meeting, the UHB has reported 40 new Serious Incidents to Welsh Government. 2 new No Surprises incidents have also been reported by the UHB during this period. All reported Serious Incidents are currently the subject of internal investigation and are monitored at the weekly serious incidents and concerns meeting led by the Executive Nurse Director. In summary, the new Serious Incidents and No Surprises reported by the UHB are as follows: Serious Incidents Clinical Board Number Description Clinical Diagnostics & Therapeutics 1 An incorrect patient received a chest x- ray on a medical ward at UHW which was also reportable to Healthcare Inspectorate Wales (HIW) as a breach of Ionising Radiation (Medical Exposure) Children and Women Regulations (IR(ME)R). 2 Two unexpected deaths of women at various stages of pregnancy have

3 Medicine Mental Health Specialist occurred. One woman had not presented to health services prior to becoming unwell due to her being in very early stages of pregnancy however, the Children and Women Clinical Board led the subsequent review process. Inpatient falls where the patients sustained significant injury, such as fractured neck of femur. Of these 9 patients, 1 has since been discharged from hospital; 7 remain as inpatients and 1 patient sadly died 3 weeks after the Unexpected death following a choking Significant self harm incident following which the patient survived. Delayed follow up of a patient following an endoscopy in Delayed endoscopy in a patient referred routinely for investigation in Medication error related to accidental ingestion of potassium permanganate soak tablets. It should be noted that the Welsh Government has recently released a related patient safety notice in relation to this known risk Unexpected deaths of patients known to Mental Health services in the community setting. Incident of violence and aggression from a patient to a member of the public. Inpatient fall where the patient sustained significant injury, such as fractured neck of femur. The patient remains an inpatient. Significant self harm incidents following which the patients survived. Inpatient fall where the patient sustained a fractured neck of femur. The patient has since been discharged. A significant medication error that involved accidental disconnection of an inotrope infusion in a Critical Care setting. Hospital acquired grade 4 pressure damage in a Critical Care setting. Unexpected death of a patient following accidental intravenous access removal.

4 Surgery A throat swab was accidentally retained in the patient s airway following extubation. This has been classified as a Never Event. In accordance with necessary process, the Delivery Unit are in liaison with the UHB to review the management and learning from this A patient underwent a procedure whereby the incorrect implant was used in the Ophthalmology setting. This has been classified as a Never Event. In accordance with necessary process, the Delivery Unit are in liaison with the UHB to review the management and learning from this Inpatient fall where the patients sustained significant injury, such as fractured neck of femur. The patients remain as inpatients following the incidents. Executive Nurse 4 There have been 4 incidents where the Procedural Response to the Unexpected Death in Childhood (PRUDiC) process has been activated. Total 40 No Surprises Clinical Board Number Description Medicine 1 A medical ward at UHL was temporarily 1 closed due to an outbreak of diarrhoea and vomiting. A significant water leak occurred within the Emergency Unit at UHW. Total 2 Welsh Government Serious Incident Closure Process The UHB is required to submit a closure form to Welsh Government on conclusion of a Serious Incident investigation process. This provides assurance on the measures that have been taken to avoid a similar incident in a similar set of circumstances. Closure forms are subject to review within Clinical Boards quality and safety mechanisms, prior to sign off by the Executive Nurse Director. The submitted closure forms are reviewed by Welsh Government who may proceed to request additional information or close the In April and May 2015, the UHB submitted 13 closure forms to Welsh Government.

5 In the same timeframe, Welsh Government closed 18 Serious Incidents having been provided with assurance on the actions taken by the UHB The learning identified from the incidents closed by Welsh Government included: Implementation of a process to improve traceability of dialysis machines Revision of admission documentation for dialysis patients, specifically to improve virology testing information Review of ligature points in Mental Health inpatient settings Revision of ward handover processes in Mental Health inpatient settings Review of suicide risk assessment documentation Ratification of a revised Observation and Enhanced Engagement Procedure for use in Mental Health Revision of observation documentation in Mental Health inpatient settings Revision of the Obstetric Escalation Procedure Revision of the Intrauterine Transfer Procedure and associated guidelines Review of confidential waste management in clinical areas Reissue of the protocol for joint working between CAMHS and Adult Mental Health Review of procedures for managing emergency adolescent admission to Adult Mental Health inpatient settings Safeguarding training for staff in Adult Mental Health undertaken Audit of case notes to ensure appropriateness of documentation Agreement that the Lead surgeon must be in the Theatre setting when the WHO checklist is undertaken Reminders to staff that pre-operative marking is to be undertaken in accordance with policy Stock availability of appropriate intravenous paracetamol vials, suitable for use in paediatric patients has been revised in a clinical setting Intravenous paracetamol administration guidance for paediatric patients has been issued to staff Intravenous pump training undertaken where a need was identified following an incident with intravenous paracetamol administration Training in relation to falls management undertaken, including dissemination of information as to immediate actions required following a patient fall Audit of completion of falls risk assessments Review of the policy related to use of bed rails