Why we have a procedure? Standard Operating Procedure 1 (SOP 1) Reporting an Incident The Trust acknowledges that, as a large and complex provider of clinical and nonclinical services, things sometimes go wrong. The organisational response, at all levels, should be to minimise their reoccurrence and wherever possible, prevent them from happening again. The overiding principle for reporting incidents is to be able to learn from incidents rather than attribute individual blame. Reporting an incident is therefore a vital part of improving patient safety and the quality of the services provided. Incidents and near misses are not in themselves evidence of neglect, carelessness or dereliction of duty. The best way to reduce incident and near misses rates is to target the underlying system failure rather than take action against individual members of staff ( fair blame ). Disciplinary action does not form part of the organisational response except in cases where one or more of the following applies: There is a second (or persistent) occurrence involving the same individual The incident requires a police investigation The action causing the incident is far removed from acceptable practice (Gross Professional misconduct) There is a failure to report an incident by a member of staff who was either involved or fully aware There is evidence of an attempt to conceal the fact that the incident occurred or to tamper with any material evidence relating to the incident The aim of this procedure is to set out the process for reporting incidents involving patients, service users, staff and others undertaking activities on behalf of the Trust. What overarching policy the procedure links to? Incident Reporting Policy Which services of the trust does this apply to? Where is it in operation? Group Inpatients Community Locations Mental Health Services all Learning Disabilities Services all Children and Young People Services all Corporate Services all Who does the procedure apply to? This procedure applies to all trust staff following an incident or near miss. All members of staff have an important role to play in identifying, assessing and managing risk. To support staff in this role, the Trust aims to build an organisational culture that provides a fair, consistent environment and does not seek to apportion blame. In turn, this Reporting an Incident Page 1 of 7 Version 1.0 September 2015
encourages an organisational climate of trust, openness and willingness for staff to report errors or near misses and to admit mistakes. When should the procedure be applied? This procedure should be followed when an incident or near miss has taken place. An incident is any event or circumstance arising from, or during,trust activities that could have or did lead to unintended or unexpected harm, injury, distress, loss or damage to a person or property, including accidents. A Near Miss is an unplanned event of a clinical or non-clinical nature, which has the potential to result in injury/harm to a person and or damage to property but was avoided as a result of the vigilance of staff or just good fortune. Near Misses are considered to be free lessons and are reportable so that taking appropriate action can reduce the potential for the event to recur in the future. Examples of events which are classified as incidents include: Any injury to a patient, visitor or member of staff A failure of equipment A failure to follow a Trust procedure Any situation which includes verbal abuse or threatening behaviour towards staff Any situation which adversely affects the planned care or treatment of a patient, including physical, verbal or mental abuse Where there is evidence of concerns relating to professional or financial misconduct How to carry out this procedure Using Datix to Report an Incident Datix is the Trust s electronic incident reporting system. You and your work colleagues will have received local training on Datix as part of your local induction to where you work. Opening Datix Via the Trust s intranet homepage, navigate to online tools > Datix Incident Reporting. Reporting an Incident Page 2 of 7 Version 1.0 September 2015
You should now see the Incident Reporting Form (sometimes referred to as the Datix Incident Form 1, or DIF1) You do not have to login to report an incident please continue Completing the Incident Report Form The Incident form comprises of 6 basic sections, which are: When and where? What Happened? Category & Grading Who s Involved? Who s reporting? Who s Responsible? Describes when the incident occurred, and the geographical location it occurred. Give a detailed explanation of what occurred, along with any actions that were taken at the time to manage or rectify the situation. Allows the incident to be assigned a type so that wider analysis can occur. Incident Grading specifies the severity of the incident. Details the people involved, and if they were harmed or not. Also allows the details of persons to be separated from any descriptions ensuring confidentiality is maintained. Captures details of the person who is reporting the incident (usually the person(s) affected, or the primary person involved). This is later used to ensure feedback is given. Stipulates which person or team needs to manage the incident, ensuring they are notified. Other sections may appear asking for more specific details, however; these only appear if relevant to the incident you are reporting, and only when required. Hints and Tips for good reporting Remember if you are unsure about anything that is being asked by the reporting form, you can click on the field help icons at anytime for a description of what is being asked. Reporting an Incident Page 3 of 7 Version 1.0 September 2015
Section 1 When and Where? Incident Date: Incident Time: Site/Location: This is the date when the incident occurred. If the incident duration lasted over several days, enter the date the incident started. If the date is unknown, enter the date the incident was discovered/ identified. Incidents need to be reported within 24 hours following the incidents occurrence, or at the earliest opportunity. This is the time at which the incident occurred. If the incident duration was over a long period, enter the time the incident started. If the time is unknown, enter the time the incident was discovered/ identified. If the time is not known, enter '00:00'. This is the Area, Site and Location, where the incident actually occurred. This may differ from where the incident/patient/staff belongs, or who is to manage the incident (e.g. the incident may happen in a patient s home but the service they belong to is Community) Section 2 What Happened? Description/Actions: Staff should use INITIALS to differentiate between the people involved in this section, please do not use names. Also ensure you are entering factual information, and not opinions or assumptions. Classification: Actual Incident: is the actual occurrence of an unexpected/ undesired event or accident. Near Miss: (or 'Close Call') is an event that took place but as a result of fortunate circumstances was prevented from reaching the stage of causing harm/ damage, such as a falling object being caught before landing on a person. Section 3 Categorisation & Grading? Grading Incidents: Incident Grading is based on a Level system that spans from 1 to 5 (1 being least severe, and 5 being most severe). Guidance can be found by clicking the? by the field. Section 4 People involved Persons Affected: If a person involved is affected by the incident, their details go in this section. Ensuring details are accurate is very important as penalties are imposed on the Trust if data is incorrect. Reporting an Incident Page 4 of 7 Version 1.0 September 2015
You can add several people to this section by simply clicking Add Another. Patients and staff details should not be mixed in this section to enable the incident to be managed and externally reported. 2 separate incident forms need to be raised if both patients and staff are affected. Alleged Perpetrator/ Here you can put the details of any alleged assailant, perpetrator or Assailant/Responsible person responsible associated with the incident. Others Involved: Here you place details of all other people who were not affected. These groups of people include witnesses, Management of Actual or Potential Aggression (MAPA) Responders, etc. Section 5 Details of Reporter Name of person: Firstly, make sure you are not reporting the incident on someone else s behalf. Section 6 Incident managed by? Incident Manager: The Incident Manager is the individual who will need to approve this report, and initiate further actions. This is usually the person in charge of the team subject to the incident; such as the team who manages the patient s care. Where an incident requires external support to take action (such as an environmental issue) it is still the Incident Manager s responsibility to arrange this external support. Immediate Action Following an Incident Once the form is completed it should be submitted by pressing the submit tab at the bottom of the page. Once submitted the report will generate an e-mail which will be sent direct from the Datix system to the reporter s line manager (Dif 2 user) or their nominated deputy, they can then access the report and check for accuracy and immediate actions taken by clicking on the link. Once they are satisfied that the incident has been managed and actions have been taken to mitigate any risks they then will select Finally Approved for incidents graded 1 2 and Being Reviewed for incidents graded 3 5. For incidents graded 3 5 the Service Manager (DIF3 user) will review the incident and actions taken, once they are satisfied that the incident has been managed and actions have been taken to mitigate any risks they will then select Finally Approved. Where do I go for further advice or information? Your Line Manager/Team Leader Your line manager/team leader is responsible for ensuring: Staff are familiar with this procedure and adhere to the instructions referred to Staff attend training applicable to their role Reporting an Incident Page 5 of 7 Version 1.0 September 2015
Ensuring all incidents are reported promptly Your local Group Governance Team Your local Governance Team will provide advice and support Group Quality and Safety Group This group is responsible for monitoring all incident reporting and associated risk issues across all areas within the division, which are discussed at monthly meetings. The Clinical Director chairs this meeting. Director of Nursing and Professional Practice Responsibility for this procedure has been delegated by the Chief Executive to the Director of Nursing and Professional Practice (Executive Lead), who will: Ensure that appropriate and robust systems, processes and procedures are in place for investigations of all incidents Lead on strategies and innovations to reduce the number of incidents occurring within the Trust Ensure that any serious concerns regarding the implementation of this procedure are brought to the attention of the Board of Directors Training Staff may receive training in relation to this procedure, where it is identified in their appraisal as part of the specific development need. Please refer to the Trust s Mandatory & Risk Management Training Needs Analysis for further details on training requirements, target audiences and update frequencies Monitoring / Review of this Procedure In the event of planned change in the process(es) described within this document or an incident involving the described process(es) within the review cycle, this SOP will be reviewed and revised as necessary to maintain its accuracy and effectiveness. Equality Impact Assessment Please refer to overarching policy Data Protection Act and Freedom of Information Act Please refer to overarching policy Reporting an Incident Page 6 of 7 Version 1.0 September 2015
Standard Operating Procedure Details Unique Identifier for this SOP is State if SOP is New or Revised BCPFT-GOV-SOP-02-1 New Policy Category Executive Director whose portfolio this SOP comes under Policy Lead/Author Job titles only Committee/Group Responsible for Approval of this SOP Month/year consultation process completed Governance Executive Director of Nursing, AHPs and Governance Patient Safety and Compliance Manager Quality and Safety Steering group September 2014 Month/year SOP was approved September 2015 Next review due Septemeber 2018 Disclosure Status Key words relating to this SOP B can be disclosed to patients and the public Datix, Incident,Procedure, SOP Review and Amendment History Version Date Description of Change V1.0 Sep 2015 New Procedure established to supplement Incident Reporting Policy Reporting an Incident Page 7 of 7 Version 1.0 September 2015