Managing Health at Work Partnership Information Network (PIN) Guideline

MANAGING HEALTH AT WORK

Guideline 9 Incident Management Policy

9.1 Definition of an incident

"Any event or circumstance arising during NHSScotland care or service provision that could have or did lead to unintended or unexpected, harm loss or damage."

In this policy, unless the context otherwise requires:

• the 1995 Regulations means the Reporting of Injuries Diseases and Dangerous Occurrences Regulations 1995;

• dangerous occurrence and major injury are each defined in the 1995 Regulations. Further information is given in Appendix 9. A of this policy;

• incident includes personal accident; clinical incident; violence/abuse/harassment; ill health; near miss; drug error/blood transfusion error;

• line manager can be defined as the person responsible for the area or work activity within which the incident took place. This includes charge nurse, supervisor, head of department, nurse in charge, estates manager or other responsible person and should be interpreted in context of the incident.

9.2 Policy statement

[Name of organisation] is committed to complying with its statutory responsibilities to ensure, so far as is reasonably practicable, the health, safety and welfare of all its staff and other persons on the premises or using its services.

It is recognised that it is not possible to prevent all untoward events. This policy aims to make sure that [Name of organisation] can meet its statutory obligations under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 1995.

This policy also aims to make sure that all incidents are reported, investigated and analysed as appropriate and that the knowledge thus gained is regularly disseminated. This will encourage and strengthen a learning culture in which care will continuously be reviewed and improved.

In the majority of cases the causes of serious incidents go far beyond the actions of individuals immediately involved. In healthcare there are a number of factors at work at any one time that can affect the likelihood of incidences occurring. It is with this in mind that we are committed to advocating a 'Just Culture'. There will however, be instances where individuals must be held accountable for their actions, particularly if there is evidence of gross negligence, recklessness or criminal behaviour. A culture where errors or service failures can be reported and discussed, lessons learned and necessary changes put in place is essential.

This policy is not for the purpose of clinical performance monitoring. If anyone is concerned with the performance or professional standard of any individual staff member, this should be reported in confidence to the appropriate professional manager.

This policy will be monitored and reviewed regularly in partnership.

9.3 Incident management protocol ( See Appendix 9.C)

9.3.1 Primary action after an incident

The priority is that the patient/staff member should receive appropriate first aid or medical treatment. The line manager must ensure that this is done, and that action is taken to prevent further danger to others. Equipment involved in the incident must be removed from use and retained for inspection. Where possible, the surrounding area of the event should be isolated, pending any necessary investigation.

If the event results in a fatality, the line manager must contact:

• the police; and

• the Health and Safety Executive (0845 300 9923).

If it is thought that a criminal act, including acts of violence, has been committed, immediate advice must be sought from the police. Call 999.

If the incident is a RIDDOR-reportable incident (i.e. a major injury; dangerous occurrence; over three-day injury; or occupational disease), then the necessary report should be made to the HSE via the incident report line (0845 300 9923).

In circumstances where a significant or serious incident arises where media interest may be generated, the organisation's media policy and procedures must be instigated. In all instances, staff and patients involved in the incident must be informed before releasing information to the media.

9.3.2 Secondary action after an incident

The line manager must make sure that an Incident Report form ( See Appendix 9.D) is completed according to the instructions detailed in the procedure, and that any necessary reports are made to the HSE.

The line manager should also make sure that when a patient is involved, the patient is informed that the event has occurred and with their consent and where appropriate their relatives are contacted and told. Transport home should be arranged for casualties if this is required.

In the event of an incident where serious harm has occurred, the line manager should arrange a de-brief session for all staff affected by the incident. Depending on circumstances, this may be conducted as one-to-one sessions or in groups. Availability of a counselling service for staff should also be considered.

The line manager must also make sure that a detailed accurate account of the incident is documented in the patient's records. This will ensure full communication is guaranteed regarding incidents, especially in cases where the patients are moving around the organisation.

9.3.3 Completing the Incident Report form

All incidents, no matter how trivial, must be reported using an Incident Report form ( see Appendix 9.D). If more than one person is directly affected by an event, a separate form must be completed for each.

As far as possible, an incident report form must be completed by the person(s) involved in the incident. The line manager may help with this if necessary. If it is not possible for the person(s) involved to complete their form, it should be completed by the line manager with help from witnesses where required. In any case, the form(s) should be completed and submitted before the personnel involved go off shift, and at the most within 48 hours of the event.

Local procedures must specify where and to whom copies of the report shall be sent. However, the following must be observed:

• In all cases, the form must be sent within 48 hours to the nominated person, for example, the Health and Safety Advisor.

• A copy should be kept in the department where the event occurred.

  • Staff report forms should be filed with departmental personnel records.

  • Patient report forms should normally be filed in the patient notes.

• If an event occurs in a communal area or off-site, a copy should go to the department with responsibility for the patient or staff member.

• If an event occurs to a visitor in a communal area, a copy should also be sent to the Health and Safety Advisor or other nominated person.

Managers should check specific local arrangements.

9.4 Data management

Upon receipt of a form, the nominated person will make or verify that a report has been made to the necessary agencies, specifically the Health and Safety Executive (HSE), using an approved system. Incident data will then be recorded in the organisation's risk management system.

Departments will be encouraged to use the collated information to monitor the effects of local risk controls and as part of their risk identification system. Incident trends and statistics will inform the development of future risk management strategies and the Organisation Risk Register.

Individual managers or departments may request data from the Health and Safety Advisor or Clinical Risk Manager where appropriate.

9.5 Incidents requiring investigation

All individuals involved directly or indirectly in patient care must report any event or circumstance arising during NHSScotland care that could have or did lead to unintended or unexpected harm, loss or damage.

To work out the degree to which the incident needs to be investigated, all incidents must be graded using an Incident Grading Matrix.

(An example of a grading matrix is set out at Appendix 9.E).

Two gradings should be documented on the Incident Report Form:

Grading 1:

Actual outcome of this incident This should be identified in terms of harm etc and the appropriate grading documented. (See Step 1 in Appendix 9.E.)

Grading 2:

Future potential risk if this incident happens again . The likelihood of a similar incident recurring in your area is selected from Step 2 in Appendix 9.E. In practice, this is subjective and will depend on the knowledge and expertise of the line manager. Staff should take expert advice if they are unsure - incidents may well fall outside the immediate experience of those involved. Wherever practicable, a consensus view should be arrived at by two or more persons with some knowledge of the potential likelihood of a similar incident recurring. Then, the most likely consequence of the incident if it did happen again is selected from Step 3. The grading is then made to establish the risk category - high, moderate, low or very low. Grading 2 can now be documented in the Incident Report Form ( Appendix 9.D).

The level of investigation for incidents is determined by the grading given for Future Potential Risk, regardless of whether the grading of the actual outcome was a near miss or serious adverse incident.

9.5.1 Very Low category incidents

All incidents should be reported. If incidents fall into the green category for potential future risk i.e. at step 3 of the matrix, a report form must still be completed and sent to the nominated person. No further action is required at department level at this time and the reports will be reviewed on an aggregate basis. Any trends that are subsequently identified can be discussed with appropriate staff and solutions determined and shared.

Each incident analysis/investigation contains a series of steps, which should be followed as a matter of routine.

9.5.2 Low to Moderate category incidents

Line managers will be required to instigate appropriate analysis and where necessary, appropriate specialists, for example, the Health and Safety Advisor or Clinical Risk Manager may be called for advice and support.

If the incident occurs as a result of a problem with, or failure of, medical equipment including infusion devices, the Technical Services manager (or equivalent person) must be informed immediately or at soon as possible if the incident occurs outwith normal working hours. This is to make sure that the equipment is withdrawn from use and that the incident is recorded in the relevant device register of Serious Adverse Incidents including subsequent action taken.

The Technical Services manager is responsible for reporting infusion device incidences to the manufacturer, the Organisational Equipment Advisory Group, the Management Executive and the Medical Devices Agency.

Incidents involving infusion devices include errors in:

• prescribing;

• dose calculation;

• rate of infusion;

• preparation of infusion solution;

• setting up of the infusion device;

• malfunctioning of the device; and

• tampering.

9.5.3 Major Category - Serious Incidents

All of these incidents will be investigated by the appropriate professional head who will take the lead. Guidance notes for significant event analysis are provided in Appendix 9.F.

The relevant professional head leading a serious incident investigation, can, where deemed appropriate, instigate procedures from local Major Emergency procedures.

If a serious incident occurs out of hours, the on-call manager should be contacted and they will inform the appropriate Senior Manager/Director as soon as possible.

9.6 Dealing with the media

Managers should expect media interest in any serious incident within the organisation, and prepare for it. NHSScotland is particularly at risk where a child or vulnerable elderly patient is involved, for example, if the wrong treatment is given, or where groups of people are at risk due to failures in a diagnostic reporting process, or if there has been an outbreak of food poisoning.

At all times patients and relatives must be notified before the media.

Communications with media will only be via the Chief Executive, other senior manager identified for the purpose or the Communications Manager. Contact can be achieved through a variety of means including a press conference, the releasing of press statements or being available for ad hoc press enquiries.