POLICY & PROCEDURE FOR INCIDENT REPORTING

POLICY & PROCEDURE FOR INCIDENT REPORTING APPROVED BY: South Gloucestershire Clinical Commissioning Group Quality and Governance Committee DATE February 2015 Date of Issue: 25 February 2015 Version No: 2 Date of Review: February 2017 Author, title: Lindsey Perryman Head of Governance and Risk 1

Document status: Current Version Date Comments Version 1 26 July 2013 Revised policy for CCG to acknowledge no provider services 1.1 October 2014 Reviewed for consideration by Policy Review Group 1.2 February 2015 Amended following review by Policy Review Group 2.0 25 February 2015 Final following approval by Quality and Governance Committee If you need further copies of this document please contact the Corporate Support Officer. South Gloucestershire Clinical Commissioning Group has made every effort to ensure this policy does not have the effect of discriminating, directly or indirectly, against employees, service users, contractors or visitors on grounds of race, colour, age, nationality, ethnic (or national) origin, sex, sexual orientation, marital status, religious belief or disability. This policy will apply equally to full and part time employees. All South Gloucestershire Clinical Commissioning Group policies can be provided in large print or Braille formats if requested, and language line interpreter services are available to individuals of different nationalities who require them. 2

CONTENTS Section Summary of Section Page Cont Contents 3 1 Introduction 4 2 Purpose and Scope 4 3 CCG s Commitment to Fair and Open Culture 4 4 Definitions 5 5 Key Responsibilities with South Gloucestershire CCG 6 6 Reporting Incidents 7 7 Members of Staff 7 8 Risk Assessments 8 9 Level of Investigation 8 10 Sharing of Lessons Learnt 8 11 Reporting to Outside Agencies 8 12 Monitoring 10 13 Related Documents 10 14 Equal Opportunities/Equalities Impact Assessment 10 15 Review Date 10 Appendix Appendix 1 Staff Incident Report Form 3

1 INTRODUCTION 1.1 This policy and procedure applies to all staff directly employed by South Gloucestershire Clinical Commissioning Group (CCG), contractors and agency staff. This policy is designed to ensure that all CCG staff have a clear understanding of their responsibilities and respond effectively to non-clinical incidents. 1.2 Incidents occurring in an NHS provider organisation or a provider that delivers care using NHS funds should be reported and investigated internally in accordance with that provider organisation s policy and procedures. 1.3 Details on how the CCG manages the reporting of Serious Incidents Requiring Investigations (SIRIs), including Never Events can be found in the separate document Policy and Procedure for the Management of Serious Incidents. 2 PURPOSE AND SCOPE 2.1 The purpose of the policy is to outline the arrangements for identifying, managing, investigating and reporting incidents and near misses within South Gloucestershire CCG. 2.2 The reporting of all incidents, including the reporting of prevented incidents (otherwise known as near misses) is designed to ensure the following: A culture of openness. Prompt and precise gathering of information. Prompt communication with staff and where appropriate, the media. Minimisation of distress caused to those affected by an incident. Identification of patterns and trends in the occurrence of incidents and prevented incidents (near misses). Minimise, so far as is reasonably practicable, future risk by taking prompt and appropriate preventative action and on-going monitoring. Early warning of potential litigation and cost impact. Review local safety procedures by managers. Fulfilment of the CCG s legal duties under statutory regulations including RIDDOR 1995, The Health and Safety at Work act 1974 and the Management of Health and Safety at Work Regulations 1999. 3 SOUTH GLOUCESTERSHIRE CCG S COMMITMENT TO FAIR AND OPEN CULTURE 3.1 An incident, regardless of its seriousness, is rarely caused wilfully. In itself, it is not evidence of carelessness, neglect or a failure to carry out a duty of care. More often errors are often caused by a number of factors including, process problems, human error, individual behaviour and lack of knowledge or skills. 4

Learning from these incidents can only take place through effective reporting and investigation in an open and supportive environment. 3.2 Determining safe practice is an important factor of effective risk management. A move away from punishment upon error to learning from them will promote a fair and open culture and safe practice throughout the organisation. This will enable the CCG to identify trends and take positive action to prevent the error or adverse incident from happening again. 3.3 To promote a fair and open culture and encourage the reporting of incidents, the CCG will take a non-punitive approach to those incidents it investigates unless there is evidence of gross professional or gross personal misconduct; repeated breeches of unacceptable behaviour or protocol; or an incident that results in a police investigation. 3.4 The CCG has an open approach where patients, relatives and carers have suffered harm as a result of an incident. They will be given an apology and an explanation as to what has happened. This does not constitute an admission of liability but an acknowledgement that untoward harm has occurred. 4 DEFINITIONS 4.1 Incident/Accident 4.1.1 An unexpected or unplanned event that caused harm, or had the potential to cause harm, to a patient, member of staff, visitor, contractor or the CCG itself. Personal accident: Personal accidents are accidental incidents which affect and/or involve a person or persons and resulted or could have resulted in injury Violence, abuse or harassment: Incidents which cannot be reasonably said to be accidental in motive and include physical assaults by any person, deliberate self-harm, aggressive incidents, and other incidents involving verbal abuse, sexual or racial harassment, or intimidation or threatening behaviour Ill health, work or environmental related incidents: Ill health which is related to work or the environment and could include hospital acquired infections, industrial asthma and eczema. Unsafe environments, flooding, lighting/power/heating failure leading to loss of services Fire incident: Any incident which involves smoke, fire, suspected smoke or fire, or fire alarm whether it be actual or suspected Security incident: A security incident is one in which there is fraud, theft, deception, criminal damage, car crime, amongst other things involving staff, visitors to the CCG and its property as well as encompassing all CCG property Information governance incident: An incident which may result in or have the potential to result in the disclosure of confidential information to 5

4.2 Near Miss an unauthorised individual, the integrity of a system or data being put at risk Clinical incident: A clinical incident is one which arises in the context of the duty of care owed to patients by members of the healthcare professions, or consequences on decisions or judgements made by those professions in their professional capacity or relevant work. 4.2.1 An event that has the potential to cause harm or was prevented from causing harm to one or more individuals, damage to property, a security breach or a confidentiality breach. 4.3 Potential Risk 4.3.1 An unexpected or unplanned event that caused harm or had the potential to cause harm to a member of staff, visitor or contractor and the situation/environment continues to propose a risk. 4.4 Serious Incidents 4.4.1 These were previously referred to as Serious Untoward Incidents (SUIs). A serious incident requiring investigation is defined as an incident that occurred in relation to NHS funded services and care resulting in one of the following: Unexpected or avoidable death of one or more patients, visitors or members of the public. Serious harm to one or more patients or where the outcome requires lifesaving intervention, major surgical/medical intervention, permanent harm or will shorten life expectancy or result in prolonged pain or psychological harm Work related death. Allegations of abuse. High profile media attention or public concerns about the organisation. Serious security related incidents resulting in loss or damage to a property or assets of the NHS, preventing the CCG from carrying out its duties. 5 KEY RESPONSIBILITIES WITHIN SOUTH GLOUCESTERSHIRE CCG The Chief Officer has ultimate responsibility for ensuring compliance with the Health and Safety at Work Act 1974 and associated legislation, and that this policy is implemented and effective within South Gloucestershire CCG. The Head of Governance and Risk is responsible for writing and implementing the policy and monitoring its effectiveness. They will ensure 6

that the policy is adhered to including the internal and external reporting components. The Caldicott Guardian is responsible for ensuring the protection and use of patient identifiable information, which may be used during the incident reporting process. The Quality and Governance Committee will review and receive incident reports to ensure that risk management issues have been addressed and to ensure that recommendations for improvements are implemented to reduce risk. 6 REPORTING INCIDENTS 6.1 The incident form (in Appendix A), should be used across the CCG to report and investigate incidents. It is the responsibility of all staff to report an incident within 48 hours (or 24 hours if it is a serious incident). 6.2 The incident form should be used to record facts of what happened, not opinions. The form should be completed as comprehensively as possible and additional sheets may be attached to the form if required. 6.3 The incident forms are located on the CCG website: www.southgloucestershireccg.nhs.uk 7 MEMBERS OF STAFF 7.1 The member of staff involved in the incident, or the person who notices it, should complete the incident form. Only one form should be completed per incident. The form should then be sent to their Line Manager for any further action, comment and signature. The Line Manager is responsible for reviewing the incident, discussing it with the member of staff reporting it and taking any additional action. 7.2 Any remedial action that is undertaken or planned should be noted on the form as appropriate by either the member of staff or the Line Manager. Completed incident forms should be forwarded to the Health of Governance and Risk 7.3 The immediate priority for all staff in the case of an incident is to take immediate steps to protect the person (or people) involved. Prompt action must be taken to prevent reoccurrence of the incident or to minimise the risk of a near miss or potential incident from becoming an actual incident. The type of action that will be taken immediately will vary according to the nature of the incident: Examples may include: Administering first aid. Removing a faulty piece of equipment Closing a work place until repairs can be undertaken 7

Consequence Changing a work practice to prevent reoccurrence 7.4 Head of Governance and Risk 7.4.1 It is the responsibility of the Head of Governance and Risk to ensure that an appropriate investigation is undertaken and that corrective action is taken. They must also ensure that appropriate feedback is given to the person who has reported the incident. 8 RISK ASSESSMENTS 8.1 All incidents should be risk assessed by the Head of Governance and Risk using the standard matrix as set out in the Risk Management Strategy, this is also copied below: Likelihood 1 Remote 2 Improbable 3 Possible 4 Probable 5 Certain 5 Fatal 5 10 15 20 25 4 Severe 4 8 12 16 20 3 Major 3 6 9 12 15 2 Minor 2 4 6 8 10 1 Insignificant 1 2 3 4 5 8.2 The basic principle is to multiply the consequence by the likelihood which then results in the risk rating. 8.3 The Head of Governance and Risk should consider any risks that are calculated as 15 or above against the criteria for a serious incident. 9 LEVELS OF INVESTIGATION 9.1 Some incidents may not require immediate investigation but most will require immediate management actions to prevent any further harm or damage. 9.2 It is the responsibility of the Head of Governance and Risk in conjunction with the Line Manager to investigate the incident, record the findings and actions taken. 10 SHARING OF LESSONS LEARNT 10.1 Incident outcomes should be shared at local level and should be considered whether the risk should be added to the risk register 11 REPORTING TO OUTSIDE AGENCIES 11.1 Health and Safety Executive RIDDOR 8

11.1.1 The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 came into force in April 1996. The CCG must report deaths, major injuries, and accidents resulting in over 7 day injury, diseases, dangerous occurrences and gas incidents. 11.1.2 The law changed on1 October 2013. If a worker sustains an occupational injury resulting from an accident, their injury should be reported if they are incapacitated for more than seven days. There is no longer a requirement to report occupation injuries that result in more than three days of incapacitation, but the CCG is still required to record these injuries. 11.1.3 The Head of Governance and Risk is responsible for carrying out all RIDDOR reporting to the HSE, if they are not available, this task will be carried out by the Corporate Support Officer. 11.1.4 In serious incidents resulting in death or major injury the HSE should be alerted immediately (www.riddor.gov.uk). If this happens out of hours this should be done by the Senior On-call Manager. 11.1.5 If there is an accident connected with work (including an act of physical violence), resulting in an employee suffering an over seven day injury, it must be reported in compliance with the above guidance within 15 days. 12 MONITORING 12.1 This policy will be monitored for compliance with reporting to external agencies. 13 RELATED DOCUMENTS 13.1 This policy should be read in conjunction with: Risk Management Strategy Information Governance policies Disciplinary Policy 14. EQUAL OPPORTUNITIES/EQUALITIES IMPACT ASSESSMENT 14.1 An Equality Impact Assessment has been completed for this policy and procedure and it does not marginalise or discriminate minority groups. 15. REVIEW DATE 15.1 This policy and procedure will be reviewed after 2 years, or earlier at the request of either staff or management side, or in light of any changes to legislation or National Guidance. 9

APPENDIX A Staff Incident Report Form Staff Incident Reporting Form South Gloucestershire Clinical Commissioning Group This form should be used to report all incidents/accidents (including Near Misses) to both patients, staff, visitors and other people Please complete in Block Capitals and use fact rather than opinion 1. Please indicate type of incident being reported (tick as many as applicable) Violence Security Accident Communication Other (please specify) Info Governance 2. Individual affected None Staff Agency worker Patient Visitor Contractor Other If patient NHS number If staff Job title Department 10

3. Details of the incident /accident Incident type: Quality issue Near miss Actual harm Date of incident Time of incident -----/-----/----- -----: ----- (24hr) Location of incident Overview of incident (record fact only, not opinion) 11

4. Details of any injury sustained Was the individual affected injured in the incident? Yes No If Yes, part of body injured Extent of injury If staff member: Sent off sick Yes No Unknown If Yes, no of days or unknown 5. Treatment received None First Aid GP Occupational Health ED Other 6. Person reporting the incident Name (please print) Practice (if applicable) Job title Date reported ----- / ----- / ----- Incident notified to: Patient/Next of kin Manager Other 7. Line Manager Name (please print) Job Title Details of discussion with member of staff and any action taken Continue overleaf 12

Signature. Date... 8. Is incident reportable under RIDDOR (Reporting of Injuries, Disease & Dangerous Occurrences Regulations) Is hospitalisation for more than 24 hours likely (or additional hospitalisation if a patient Yes No N/A Has death of a major injury occurred Yes No N/A Staff only: Incapacity to work more than 7 days Yes No N/A Work related illness/condition Yes No N/A Incident Reported to HSE Yes No N/A 13