Incident Reporting Procedure - Tower Hamlets CCG
Incident reportingprocedureNumber:THCCGCG0045 Version:V0d1 All incidents must be reported. This should be done assoon as practicable after the incident has beenidentified to ensure that the most accurate andcomplete information is recorded. The reporting of incidents is an important means ofproviding information that allows the CCG toinvestigate such occurrences quickly. Other parties may need to be involved in theinvestigation dependant on the type of incident whichhas occurred. The incident report form is included as an appendix tothis procedure and is available from the Governanceand Risk Manager.Executive SummaryDate of ratificationExecutive Team - January 2014Document Author(s)Paul Balson – Governance and Risk ManagerWho has been consulted?Archna Mathur – Deputy Director Quality and Performance –November 2013Was an Equality AnalysisNorequired?With what standards doesthisdocumentdemonstrate compliance?January 2014 Serious Incident Reporting and Learning Framework(SIRL) Reporting of Injuries, Diseases, and DangerousOccurrences Regulations 1995 MHRA DB2005(01) January 2005 Seven Steps to Patient Safety. National Patient SafetyAgency 2004 Clinical Negligence Scheme for Trusts, Mental Healthand Learning Disability Clinical Risk ManagementStandards, NHS Litigation Authority, April 2012Incident reporting Policy and Procedure1
ommendedperiodandCCGapprovalsreview THCCGCG45 Whistleblowing Policy THCCGCG1 Integrated Risk Management Framework THCCGCG39 Information Security Policy THCCGCG40 Information Sharing and DisclosurePolicy THCCGCG6 Gifts, hospitality and anti-bribery Policy THCCGCG8 Information Governance policy THCCGHS19 Health and Safety Policy THCCGHS21 Lone Worker Policy and Procedure THCCGHS25 Security Policy THCCGIG20 ICT Policy THCCGIG36 Data Encryption Policy THCCGIG37 Email Policy THCCGQI33 Safeguarding Children Policy THCCGQI34 Safeguarding Adults Policy THCCGQI5 Complaints PolicyExecutive Team – January 2014October 2015Health and Safety, Incident book, Incident report form,Key words contained inincidents, Investigation, IRF, near misses, RCA, RIDDOR,documentRoot Cause Analysis, Serious Incident , SIIs this document fit forYthe public domain? Y / NJanuary 2014If ‘No’why?Incident reporting Policy and Procedure2
1Purpose and scope. 42Examples of Incidents. 53Responsibilities. 65Definitions. 86Procedure . 97Training . 168Management and use of incident data . 169Monitoring, Audit and Evaluation . 18Appendix 1: THCCG Incident report form . 19Appendix 2: THCCG Risk Grading Matrix . 22January 2014Incident reporting Policy and Procedure3
1Purpose and scope1.1PurposeThis document outlines NHS Tower Hamlets Clinical Commissioning Group’s approach toincident reporting. The aims of this policy are:1.2 To describe the process for reporting and recording incidents. To encourage the prompt and consistent reporting of all incidents, and nearmisses. Some examples of incidents are included below at 1.4 Examples ofIncidents To ensure investigation of incidents and near misses. To provide a feedback mechanism and organisational learning from incidents andnear misses.ScopeThis policy and procedure applies to all staff, teams and activities managed or participated inby NHS Tower Hamlets Clinical Commissioning Group.1.3PolicyNHS Tower Hamlets Clinical Commissioning Group recognises that on occasions, untowardincidents and near misses will occur that result in or have the potential to cause harm, injury,damage or loss. Although this does not happen very often, when serious failures do occurthey can have a huge effect on staff and also undermine staff, public or others’ confidence.The reporting of incidents is an important means of providing information that allows theCCG to investigate such occurrences quickly. It helps with the process of identifying thecauses of such incidents from which lessons can be learned and control measures put inplace to reduce the risk of recurrence.January 2014Incident reporting Policy and Procedure4
2Examples of IncidentsJanuary 2014Incident reporting Policy and Procedure5
3ResponsibilitiesRoleAll staffStaff memberrecognising anincident.ManagersGovernance andRisk ManagerJanuary 2014Responsibilities Attending mandatory and statutory training as indicated by theCCG Co-operating with this Incident Reporting Procedure Reporting risks, incidents and near misses report near misses, adverse incidents and serious incidents Initiate a suitable response to the incident to ensure it cannotreoccur. Record and report the details of the incident on the CCG Incidentreport form Ensure that the response to the incident is adequate, taking thelead where appropriate. Review incidents, with the aid of incident reports, to ensure thatthey are adequate and completed. Initiate investigation where necessary Promote an open and honest environment in which staff areencouraged to report incidents, as well as being involved ininvestigations and improvement activities. Ensure implementation of the incident reporting policy andprocedure. Monitor, ensure implementation of, and report on implementationof action plans arising from incidents. Central recording of information about incidents. Support and advice to staff about all aspects of incident reporting,investigation, and improvement activities. Reporting of incident details to external agencies whereappropriate. Day to day risk management and corporate incident managementactivity within NHS Tower Hamlets CCG. Ownership and implementation of the Incident ReportingProcedure, Risk Management Framework and the Health andSafety Procedure Development and maintenance of the Assurance Framework Facilitation of access to external legal adviceIncident reporting Policy and Procedure6
RoleResponsibilities Communicating learning from incidents with stakeholders andmembers (this responsibility may be delegated on an incident-byincident basis where appropriate) responsible for the development and implementation of effectiverisk management arrangements and systems of internal control. Overall responsibility for investigating incidents relating toinformation governance and fraud Overall responsibility for ensuring an effective risk managementsystem is in place within NHS Tower Hamlets CCG. Provides an advisory role for incidents involving patientconfidentiality and information sharing issues. Must be informed of any incidents involving patient confidentialityand information sharing issues. If an incident relates to Information Security and / or InformationGovernance; report to the Health and Social Care InformationCentre (HSCIC), NHS England and / or the InformationCommissioner's Office (ICO) where there is need. Promote an open and honest environment in which incidents, andpotential incidents, are reported and learning is an integral part ofhow things are done. Maintain assurance of the effectiveness of incident reporting andmanagement systems and processes. Maintain an awareness of key themes arising from incidentanalysis. Ensure the Governing Body is kept informed of key issues. Agree and monitor health and safety arrangements andcompliance Agree and monitor the CCGs Incident Reporting Policy andProcedure Review any serious incident reports and ensure that lessonslearned are disseminated across the organisation.Head ofEngagementDeputy DirectorQuality andPerformanceChief FinanceOfficerSenior InformationRisk Owner (SIRO)Chief OfficerCaldicott GuardianInformationGovernance TeamNELCSUExecutive TeamJanuary 2014Incident reporting Policy and Procedure7
55.1DefinitionsHazardAnything (object, event, process) that has the potential to cause injury, damage or loss to theorganisation, patient, staff, visitor or other.5.2IncidentAn incident is usually an event that contains one or more of the following characteristics: is contrary to plans for, or implementation of, the specified standard of patient careresulting in harm or potential harm, places some patient(s), client(s), staff member(s) or visitor(s) at unnecessary risk, results in harm or potential harm to one or more patient, client, staff member or visitor, puts the CCG in an adverse legal and/or media position with loss of reputation.This includes all incidents which are likely to have a bearing on the quality, safety,operational efficiency or reputation of the CCG. The scope extends to all incidents thatinvolve inter-organisational issues, particularly those relating to the Commissioner / Providerinterface. E.g. The Communication of Patient Identifiable Data across unprotected networks.A few examples of Incidents are included at 1.4 Examples of Incidents.5.3Near MissAny event or omission where an incident almost occurred which had the potential to causeharm, injury, damage or loss but failed to develop, whether or not as a result ofcompensating action.5.4Serious IncidentA serious incident is an incident that occurred in relation to NHS-funded services and careresulting in one of the following: unexpected or avoidable death of one or more patients, staff, visitors or members of thepublic; serious harm to one or more patients, staff, visitors or members of the public or wherethe outcome requires life-saving intervention, major surgical/medical intervention,permanent harm or will shorten life expectancy or result in prolonged pain orpsychological harm (this includes incidents graded under the NPSA definition of severeharm); a scenario that prevents or threatens to prevent a provider organisation’s ability tocontinue to deliver healthcare services, for example, actual or potential loss ofpersonal/organisational information, damage to property, reputation or the environment,or IT failure; allegations of abuse; adverse media coverage or public concern about the organisation or the wider NHS; one of the core set of ‘Never Events’ as updated on an annual basis.January 2014Incident reporting Policy and Procedure8
6ProcedureBelow is a summary of the incident reporting procedure. Additional details are contained inthe following sections.January 2014Incident reporting Policy and Procedure9
6.1Incident identifiedAn incident is defined at 4.2 Incident. They can be identified by anyone (not just employeesof the CCG). A number of examples are listed at 1.3 Examples of incidents.For advice or guidance on what constitutes an incident, please contact the Governance andRisk Manager – 020 3688 2522.6.2Respond to the incidentThe initial actions to take are:6.2.1Assess and treat any injuriesIf a person is injured, make an assessment to ascertain if it is safe to approach the injuredindividual. Assess the injuries and either call for the first aider or an ambulance.6.2.2Provision of supportWhere appropriate, people affected by or involved in incidents will be provided with suitablesupport to help them deal with any issues that they face or enable them to be involvedadequately in the processes that result. This will include advice about relevant advocates,external agencies, and resources.6.2.3Secure the sceneSecure the scene in the event of a burglary or criminal damage.6.2.4Notify relevant stakeholders (patients, staff and other agencies)Assess the situation and decide who may need to be contacted. E.g. The host organisation,Police, Ambulance Service, Fire Brigade, next of kin, etc.6.3Report the incidentThe individual first identifying the incident should report facts no opinions on the NHS TowerHamlets CCG incident report form. The form should then be given to the manager of thearea where the incident occurred.This is available at Appendix 1: THCCG Incident report form or from the Governance andRisk Manager.All incidents must be reported. This should be done as soon as practicable after the incidenthas been identified to ensure that the most accurate and complete information is recorded.The information recorded will be used for a variety of purposes, including:January 2014Incident reporting Policy and Procedure10
If a staff member feels sufficiently uncomfortable about reporting an incident in the standardform, they should consider using the THCCG Whistleblowing policy.6.4Line Manager ActionsThe Line Manager should review the incident ensuring: A member of the Senior Management Team are informed If the incident is serious orpotentially serious That the initial remedial action is sufficient. That there is no Personal Identifiable Data or opinions in the incident description. Justfacts. Identify outstanding issues and initiate relevant action.6.5InvestigationAll incidents have risk potential and must be reviewed by the line manager.Every incident will require an assessment to establish the cause. This will range from aminimal investigation where the root cause is known and is already being addressed throughother means, or the incident has been risk assessed and is as low as it can be, to a seriousincident which will give rise to a full and immediate investigation.In some instances a more detailed investigation may be necessary. The level of investigationinitiated is determined by the manager; however scenarios where it would appropriate arelisted below:January 2014Incident reporting Policy and Procedure11
6.5.1Incident severityThese will be low risk, simple events, dealt with by theperson in charge at the time.LowSuggested level 1Investigation or as necessaryThe amount of information required is likely to be entirelycontained within the incident form.The frequency of this type of event should be givenscrutiny and consideration given to carrying out a riskassessment.These may require more detailed planning as to what isrequired but management is likely to remain within thelocality / specialty.MediumSuggested level 1 or 2InvestigationExtremeSuggested Level 2 or 3InvestigationThe incident form will usually be a sufficient record of anyfindings, but more detail may be required than for ‘low’incidents.The line manager should read any investigation anddetermine what actions are required to reduce or removethe risks, and any underlying causes, organisational,environmental, team or individual. A risk assessment maybe required.These incidents are likely to have, or could have, asignificant outcome and may require more in depthinvestigation.A risk assessment will, in most cases, also be required.Root Cause Analysis should be considered for incidentsthat trigger external investigations.6.5.2Level 1 – Concise Investigation: Most commonly used for incidents that resulted in no, low or moderate harm Commonly involves completion of a summary or one page structured template. Includes the essentials of a thorough and credible investigation, conducted in the briefestterms. Involves a select number of Root Cause Analysis toolsJanuary 2014Incident reporting Policy and Procedure12
6.5.3Level 2 – Comprehensive Investigation Commonly conducted for actual or potential ‘severe harm’ outcomes from incidents Conducted to a high level of detail, including all elements of a thorough and credibleinvestigation Includes use of appropriate analytical tools (e.g. tabular timeline, contributory factorsframework, change analysis, barrier analysis) Conducted by staff not involved in the incident, locality or directorate in which it occurred Overseen by a director level chair or facilitator May require management of the media via the organisation’s communicationsdepartment. Includes robust recommendations for shared learning, locally and/or nationally asappropriate. Includes a full report with an executive summary and appendices.6.5.4Level 3 – Independent investigationAs per Level 2, but in addition: Must be commissioned and conducted by those independent to the organisationinvolved. Commonly considered for incidents of high public interest or attracting mediaattention.6.5.5Root Cause AnalysisA full investigation of a serious incident is known as ‘Root Cause Analysis’. The term is usedto describe the process necessary to establish the true cause of a problem and the actionsnecessary to eliminate it.The prime objective of any investigation is to learn from the experience and ensure it is notrepeated. This is achieved by:Determining the sequence of events leading to the incident Determine what was managed well Determining the human, organisational and job factors that gave rise to theincident or condition(s) Identify the root causes Initiating short-term action to eliminate the immediate causes and establishing alonger term plan to correct the underlying human, organisational and job factors.The following are helpful links to the National Patient Safety Agency (NPSA) investigationtools and templates: Root Cause Analysis (RCA) report-writing tools and templates Root Cause Analysis (RCA) investigation report writing templatesJanuary 2014Incident reporting Policy and Procedure13
6.5.6Additional expertiseOther parties may need to be involved in the investigation dependant on the type of incidentwhich has occurred, e.g. Information Governance, Security, Health and Safety or InfectionControl. However, the service involved is responsible for investigating the incident.6.5.7Incidents involving multiple organisationsWhere this is the case an appropriate senior manager should make sure that all of theorganisations involved are aware of the incident, and if possible involved in the investigationand determination of improvement strategies.6.5.8North East London and the City wide analysisSometimes there is insufficient value in very detailed investigation of isolated incidents inone CCG. Where a number of similar incidents occur in a relevant time period acrossseveral CCGs in NELC, these should be considered for further investigation as a sector.A structured team approach such as Significant Event Audit should be used for theinvestigation. Identification of suitable incidents should occur at corporate level.6.6LearningLearning is an important part of being able to improve services and reduce risks for patients,staff, and visitors to the CCG. Unexpected complications and good practice identified in onearea can be used to improve systems and processes across the CCG, and feed into thedevelopment of new services, systems and processes in the future.Learning points can potentially be identified from all aspects of an incident, the investigation,and related improvement activities. It is usually appropriate to extract learning points throughstructured review at the end of processes and projects, and it is expected that this will be thenorm.Learning points that are identified should be: Stored in a way that facilitates later reference by a wide range of people. Shared with key people and groups that may have an interest as soon as possible.January 2014Incident reporting Policy and Procedure14
6.6.1Improvement strategiesOnce the contributory factors, and preferably the root causes (causal factors), have beendiscovered by the investigation, appropriate improvement strategies should be identified andactioned.These activities may be undertaken by the people in
Reporting of incident details to external agencies where appropriate. Day to day risk management and corporate incident management activity within NHS Tower Hamlets CCG. Ownership and implementation of the Incident Reporting Procedure, Risk
Key terms in incident reporting in NHSN Required Incidents reporting . Coming Up Next Optional Incident reporting Incident case studies . 20 . So far, the key terms in incident reporting and required Incidents reporting have been covered. Next, optional Incidents repor\൴ing as well as incident case studies will be discussed.
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Policy Number: BQIS 460 0301 008 Incident Reporting/Review 6 Contact Information for Incident Reporting & Management Questions regarding incident management/reporting can be directed to the BQIS Incident Reporting Department through e-mail BDDSIncidentReports@fssa.
Incident Management Process Map 1. Incident Management Process Map 1. Incident Management Description and Goals 9. Incident Management Description and Goals 9. Description 9. Description 9. Goals 9. Goals 9. Incident Management RACI Information 10. Incident Management RACI Information 10. Incident Management Associated Artifacts Information 24
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6.1 How to Raise and Manage an Incident on the Datix Incident Reporting System 15 6.2 Incident Severity Grading 16 6.3 Quality Checking 17 6.4 Reporting to the National Reporting Learning System (NRLS) 17 6.5 The Management of a Serious Incident 18 6.6 Never Events 19 6.7 Learning From Incidents 19
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