Connecting Local Health
and Social Care Services
Appendix B
Core Care Links Ltd
Incident Reporting Policy
Any locally held old paper copies must be destroyed. When this document is viewed as a
paper copy, the reader is responsible for checking that it is the most current version.
This can be checked on Core Care Links website
Date Agreed at Directors Meeting: 2nd January 2013
To be reviewed: November 2013
Core Care Links Incident Reporting Policy – November 2012
Document Reference No:
CCL –IR-2012
Version 1
Lead Director:
Dr Martin Clausen
Director Lead - Governance, Compliance and
Complaints.
Author:
Anna Morgan
Manager – Core Care Links Ltd
First Version Issued On:
TBC
Review Date:
November 2013
(To be reviewed annually)
Approved By:
CCL Directors
Date: 2nd January 2013
Target Audience:
All staff working for or on behalf of Core Care
Links
Dissemination:
CCL Website (staff Section)
Email to all Staff
CCL Incident Reporting Policy November 2012
CORE CARE LINKS
INCIDENT AND ACCIDENT REPORTING POLICY
1.
INTRODUCTION
As part of Core Care Links Ltd (CCL) commitment to the management of risk and to improve
the quality of care provided, an organisation-wide incident reporting system for reporting
incidents or accidents is in operation. This is an essential element of CCLs Risk Management
Strategy and its effectiveness depends upon the cooperation and involvement of all staff
working for and on behalf of CCL.
If used effectively the incident reporting system provides an 'early warning' of actual and
potential claims, complaints, or adverse publicity and means the CCL is prepared for such an
occurrence. It strengthens the CCL’s position in the event of litigation by enabling CCL to
obtain the necessary information at the time of the incident when memories are fresh.
Where actual incidents of loss or harm have occurred, it enables early notification and
explanation to the 'injured' party to occur and, where necessary, swift compensation to the
justified claimant.
The purpose of incident reporting is to ensure all accidents or incidents (actual and
potential) are recorded, reported and managed. This enables the CCL to learn lessons from
mistakes made and take prompt action to prevent and minimise recurrence. It enhances
CCL’s ability to continually develop good practice and improve the quality of care. It also
protects the individual: patients, staff, contractors, volunteers and visitors through the
provision of a safer environment.
The incident reporting system also sets out the procedure to be followed to ensure that
sufficient information is obtained to meet statutory reporting requirement.
2.
FAIR AND EQUITABLE CULTURE
Fear from disciplinary hearing and subsequent sanctions may deter staff from reporting
incidents. CCL's incident reporting system has therefore been developed within a culture of
'fairness and equity'. Where errors have occurred and are openly reported, an investigation
into the facts may take place but the disciplinary process will not be instigated against any
member of staff except in well defined circumstances as follows:
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An incident which is a fundamental breach of professional practice;
An incident which might lead any professional registration body to review the
individual's professional status;
Further occurrences of an incident where the individual has previously received
counselling relating to rectifying the type of error that might have led to the incident;
Where an incident has led to criminal actions involving the police or a registration or
regulatory body with statutory powers;
Failure or significant delay in reporting an incident in which a member of staff was
directly involved or about which they were aware.
CCL Incident Reporting Policy November 2012
This recognises the fact that most errors are made because of a system failure and the
purpose of incident reporting is to improve the system.
It should be noted that when any error is being considered, whether within the
Incident/Accident Reporting Policy structure or not, it is universally recognised that when a
member of staff is open in admitting to the error and reporting it to the appropriate
individual, a considerably more positive and supportive approach may be taken by CCL in
addressing the matter. Conversely, it is also the case that when a member of staff decides
to either delay reporting, or to attempt to conceal the occurrence of an error, CCL’s
response to it is likely to be less favourable and will indeed specifically address this delay or
failure to report as a further element of the issue.
3. FIRST ACTIONS
Timescales for reporting are detailed within this Policy as are how to report an
Incident/Accident. The first action of staff must be to ensure the immediate safety of the
situation that caused the incident/accident. The action required is obviously dependent on
the individual occurrence but, as a general rule, the area must be made safe. Advice can be
sought from the Operational Supervisor on call on 07535 650873. Patients, the public and
service users must be kept informed on any issues that may endanger their safety. Any
remedial action taken by staff should be documented on the incident report, as should any
discussions with patients or relatives.
If an incident occurs because of malfunctioning equipment, this should be removed and
consideration given to the probability of the incident reoccurring either with this piece of
equipment or others in use at other premises. Any faulty equipment should be reported to
CCLs Operational Supervisor.
Staff must ensure that any witness statements are taken and their details recorded on the
Incident/Accident report.
4.
WHAT TO REPORT
Staff must report all incidents, accidents, concerns or potential (i.e. ‘near miss’) incidents
that have or could adversely affect the individual(s) involved (i.e. lead to loss, harm or
damage), lead to dissatisfaction or further action and ultimately loss to the CCL’s reputation
and assets. This applies whether the ‘affected’ person is a patient, member of staff,
contractor or visitor to CCL.
The following 'trigger list' has been developed as a guide to the type of incident that should
be reported. The list, however, is not exhaustive:
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Failure or delay in referring or admitting to hospital or delay in providing treatment
Failure or delay in diagnosis, incorrect diagnosis, incorrect treatment
Treatment problems, allergic reactions, unexpected complications, unexpected death
Failure of follow-up arrangements
Failure to act on abnormal test results
Slips, Trips and Falls
Medication errors, immunisation or vaccination errors
CCL Incident Reporting Policy November 2012
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Consent issues
Medical records problems
Infection control issues
Lack of adequate facilities/equipment/resources (including staffing levels)
Medical and Non Medical Equipment malfunction
Security - theft, vandalism, violent and abusive behaviour, including verbal abuse
Accident with or without injury
Needle stick injury
Administrative errors such as unreadable handwriting
In addition, events will often occur which are unexpected. These events are usually not
related to negligence but may be viewed as such by the patient or their relatives. To the
doctor or healthcare professional the unexpected event may be a recognised complication
of a particular treatment. Given the potential for dissatisfaction, such events should also be
reported.
It should be stressed, however, that this list is not exhaustive. An element of judgement is,
therefore, required as to whether an incident should be reported but where doubt exists the
safest option will be to report the incident. Advice can also be sought from the Operational
Supervisor.
The completion of an Incident/Accident report does not constitute an admission of liability,
either on the part of the person making the report or any other individual involved. It is
important, however, that only the facts pertaining to the incident and not opinions are
recorded.
NOTE: Anonymous reporting is viewed as the exception rather than the rule as it can often
prohibit a thorough or adequate investigation but would be acceptable if the incident would
not otherwise be reported.
All incidents/accidents relating to patient safety are reported to the National Patient Safety
Agency (NPSA) via the National Reporting and Learning System (NRLS). This is undertaken via
the NPSA website by CCL Management. There are certain incidents that must also be reported
to the regulator of NHS services (Care Quality Commission). This is also done by CCL
management, therefore all staff have a duty to report an incident or accident as per Section 5
of this policy without delay.
4.1
Being open - communicating patient safety incidents with patients and their carers
Communicating honestly and sympathetically with patients and their families when
things go wrong is a vital component in dealing effectively with errors or mistakes in
their care. The NPSA’s Being Open policy is part of a national drive to help
healthcare staff with this difficult task. The principles of Being Open are:
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Acknowledgement
Truthfulness, timeliness and clarity of communication
Apology
Recognising patients and carer expectations
Professional support
Risk management systems and improvement
CCL Incident Reporting Policy November 2012
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Multidisciplinary responsibility
Clinical Governance
Confidentiality
Continuity of care
Comprehensive guidance can be found at:
http://www.nrls.npsa.nhs.uk/resources/?entryid45=65077 Being Open Framework
4.2
Serious Incidents (SI)
A SI may be defined as an incident where a patient, member of staff, or member of
the public has suffered serious injury, major permanent harm, or unexpected death
or where there is cluster/pattern of incidents or actions by staff which have caused
or are likely to cause significant public concern.
‘Near misses’ may also constitute Serious Incidents, where the contributory causes
are serious and under different circumstances they may have led to serious injury,
major permanent harm, or unexpected death, but no actual harm resulted on that
occasion. A possible example is that of a system failure, the result of which is
incorrect/delayed diagnosis. This may not have any serious consequences for some
patients, but for others could lead to the wrong treatment/serious delay in
treatment and ultimately to death.
For more information on how to report an SI, please speak to CCLs Operational
Supervisor.
4.3
RIDDOR Incidents
Under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations
(RIDDOR), the CCL has a responsibility to report to the Health and Safety Executive
(HSE) certain incidents or accidents that occur. Early notification of accidents or
incidents means that the CCL is able to comply with RIDDOR requirements.
Cases of over-three day injuries must be notified within ten days of the incident
occurring to the HSE. This also includes where a member of staff is unable to
perform their full range of duties after a three-day period. Staff must indicate
RIDDOR-reportable incidents when completing the Incident/Accident report form
Duties for the CCL as an employer
As an employer, CCL must report any work-related deaths, injuries, cases of disease,
or near misses involving its employees wherever they are working.
If you are an employee
If you are a member of CCL staff or work on behalf of CCL and have been injured at
work, seen a dangerous occurrence, or your doctor has certified that you have a
work related reportable disease, you must complete an Incident/Accident report
form.
CCL Incident Reporting Policy November 2012
4.4
IT Security Incidents
In accordance with the Care Trust Plus’ IT Security Policy, and CCLs Confidentiality
Policy, which aims to ensure that security requirements and the requirements of
the Data Protection Act are met, all breaches or potential breaches of security on IT
and related systems should be reported to the Operational Supervisor immediately
and reported via an Incident/Accident reporting form including immediate actions
taken. This will allow for identification of trends in incidents.
4.5
Violence, Abuse and Harassment
Any incidents or near misses that involve violence, abuse or harassment should be
report via the standard Incident Reporting Form. In addition, a Violence, Abuse and
Harassment form should be completed (Appendix B).
4.6
Fraud
Where an incident involves or suspected involvement of fraud, advice should be
sought from the Care Trust Plus’s Local Counter Fraud Specialist (LCFS) (contact
details available via the CTPs Intranet). All incidents of actual or suspected fraud
must be reported via an Incident/Accident report form. CCL will ensure that the
LCFS is informed.
4.7
Safeguarding
All incidents, when initially reported as well as when reviewed by ccl should always
consider that they may be an element of adult or children’s safeguarding that
requires specific input during the incident reporting and Investigation. If a member
of staff suspects a safeguarding issue, or wishes to raise this for specialised
safeguarding review and input, s/he must make this clear on the incident reporting
form. This will prompt CCL to engaged the relevant safeguarding lead, who will state
whether the safeguarding review process is necessary for this incident or not.
4.8
External reporting
As per Section 4.0 all clinical incidents must be reported to the National Patient
Safety Agency and should be reported by clinical areas via the incident reporting
form without delay. This includes incidents such as safeguarding allegations and any
serious incidents. Disruption to registered provider services for more than one day
must also be reported directly to the Care Quality Commission and should be
notified via the incident reporting form without delay.
5.
HOW TO REPORT AN INCIDENT OR ACCIDENT
The CCL has adopted a universal process for the reporting and recording of all incidents
including ‘near misses’. Incidents and Accidents are logged and reported on the Incident
Reporting form (Appendix A) which is available to all staff via CCLs Website.
CCL Incident Reporting Policy November 2012
All staff must use this form to report incidents. Completed forms must be forwarded to CCLs
Operational Supervisor (Sophie.cooper4@nhs.net) immediately. In the first instance,
incidents and accidents should be reported within one day of the incident.
If the incident/accident has led to death or serious injury, the incident must be reported
immediately and the person reporting the incident should follow this up with a telephone call
to the Director for Governance, Compliance and Complaints. If neither is available, one of the
other Directors should be contacted. Such incidents may be classified as Serious Incidents and
require immediate and more detailed investigation.
6.
INVESTIGATION OF INCIDENTS
Unless the causes of adverse incidents are properly understood, lessons will not be learnt
and suitable improvements will not be made to secure a reduction in the risk of harm to
future patients, staff and visitors. However, not all incidents need to be investigated to the
same extent or depth. In the majority of instances, incidents will be minor or near miss and
the cause of the incident will be clear and it will be the responsibility of CCL Operational
Supervisor to ensure that the appropriate remedial action is taken to ensure, as far as
possible, there is no recurrence.
Incidents will be routinely discussed at Team meetings to review the outcome and learning
from the events.
Health and Safety and Waste Management Incidents and Accidents
For Incidents in relation to Health and Safety or waste management, the Correctable Cause
Analysis should be completed and appropriate action taken to address the cause of the
incident. If further advice is needed on assessing or addressing Health and Safety or Waste
Management incidents, further advice can be sought via CCLs Operational Supervisor.
7.
Learning the Lessons
Follow-up and ‘closing the loop’ following incidents is a key requirement of the incident
reporting process. Without learning and change arising from incidents, aggregate review
and wider experiences, the quality of care provided to patients and the safety of staff,
patients and visitors will not improve.
As indicated above, in the majority of instances, incidents will be minor or near miss and the
appropriate remedial action can be taken at the time the incident occurs. Where relevant,
following more serious incidents, an action plan will need to be prepared and shared with
the relevant staff.
Where training is part of an action plan it should be appropriate, identify competencies to
be achieved and evaluated. There should be a clear indication of how training will be
continued and developed in the future.
8.
MONITORING AND AUDIT
Incident and accidents are monitored by the Directors and Management of CCL to ensure
appropriate reporting and actions are being taken. Individual reports are also discussed on a
monthly basis with the Care Trust Plus.
CCL Incident Reporting Policy November 2012
APPENDIX A
INCIDENT / ACCIDENT FORM
Please note that facts, not opinions should be recorded. All entries will be treated in the strictest confidence
What is it You Wish to Report?
Near miss
Actual incident / Accident
Incident Type Affecting
Patient/Service user
Core Care Links
Concern
Staff
Other Organisation
Visitor / Member of public
Contractors / Sub Contractors
Person Affected
Surname:
First Name:
Address:
Contact Number:
Date of Birth:
Work Email:
IF PATIENT/SERVICE USER
ID number e.g. SWIFT / NHS No:
Details of Incident
Date of Incident:
Time of Incident:
Type of Location (Please enter the type of location where the incident/accident occurred or is thought to have occurred) i.e. Hospital, Pt / Service User Home
Exact location
(Please enter the exact location where the incident/accident occurred or is thought to have occurred) i.e. Ward 6,
Description of incident:
Immediate Actions Taken
Did the Incident / Accident involve
Medication
Medication Incident Details
Administration / Supply of
medicine from a Clinical area
Preparation of medicines
dispensing in pharmacy
Equipment
Violence (please fill out Appendix A)
Advice
Monitoring / follow up of medicine use
Prescribing
Supply or use of over the counter
medicine
Medical & Non Medical Equipment
Did faulty equipment play a part in this incident? Yes
If yes:
Product Type:
Serial Number:
Description of Device
CCL Incident Reporting Policy November 2012
No
Brand Name:
Manufacturer:
Have you notified anyone of the equipment shortfall/failure? *Yes
No
*If yes, who:
Details of Injury
Was the individual affected injured by the incident?
*Yes
No
*If yes:
Description of the injury: i.e. Allergic Reaction
Body part affected: Left Leg, Sacrum
Was a staff member off sick due to the incident?
*If yes, please specify the number of days:
Was the injured person taken to hospital? Yes
*Yes
No
No
Treatment Received
None
999 Called
Referred to Dr
on site
Referred to
Nurse on site
Assessed &
Treated
Referred to
Occupational
Health
First Aid
On Sick
Leave
Referred to
A&E dept
Referred to
own GP
Treatment
Given
Other
Description of treatment:
People Involved
Person Affected
Surname:
Witness
Other Contact
First Name:
Date of Birth:
Address:
Assailant
Contact Number:
IF PATIENT/SERVICE USER
ID number e.g. SWIFT / NHS No:
Person Affected
Surname:
Witness
Other Contact
First Name:
Date of Birth:
Address:
Assailant
Contact Number:
IF PATIENT/SERVICE USER
ID number e.g. SWIFT / NHS No:
Person Reporting/Filling in this Form
Surname:
First name:
Job Title:
Directorate/Department:
Address: (if staff work base)
Contact number: (if staff work number)
Date reported:
Signature:
Incident notified to: Patient/Service User
*If other please specify:
Next of kin
Manager
*Other
Completed forms should be sent to Sophie Cooper, Operational Supervisor (Sophie.cooper4@nhs.net) / 07535
650873
CCL Incident Reporting Policy November 2012
Violence/Abuse/Harassment - Incident / Accident Appendix A
Please note that facts, not opinions should be recorded. All entries will be treated in the
strictest confidence.
Details of
Assailant/Aggressor:
Full Name:
Gender: M / F
Type of Incident (Please tick the classification box (es) which most closely resembles the incident)
Verbal Abuse
/ Assault
Criminal
Damage
Attempted
Assault
Actual Physical Assault
Robbery
Theft
Racial
Abuse
Sexual Offence
Contributory Factors (Please tick the contributory factors box (es) which most closely resembles the incident)
Drugs/Alcohol
Angry during 1:1
counselling/interview
Argument with another
client/patient
Disagreement about care
programme
*If other, please specify:
Objecting to personal
care given
Objecting to taking
medication
Response to staff
requests
Response to staff
restraining
Persecutory delusions
In pain (physical)
Attempting to leave
Confused state
Command hallucinations
In/out of seclusion
Burglary
Other
Action Taken
Successful de-escalation
Restraint – escorted/assisted (standing)
Given Rapid Tranquilisation
Seclusion
Restraint – full restraint (on floor, or knees or force used)
Completed forms should be sent to Sophie Cooper, Operational Supervisor (Sophie.cooper4@nhs.net) / 07535
650873
Feedback Section
Name of Reporter
Name of Line Manager
CCL Incident Reporting Policy November 2012