Incident Reporting Training

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Incident Reporting Training
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Incident Reporting Background

• Current Trust wide incident reporting has been
  in operation since April 2003
• Supported an increase in centrally reported
  incidents (Over 8000 incidents reported to the RM
  Dept (2004 05).
• However many weakness in the system have been
  highlighted
• New Governance IT System

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Objectives of Modified Incident Reporting Form

• Staff efficiency - in complete IR form
• Form Detail increase in usefulness of the
  data collected from IR form
• Increase efficiency of data entry to IT
  Governance System
• Increase Robustness transparency though
  system.
• Complete incident reporting cycle e.g. increase
  Incident Reporting feedback
• Increase reporting though out organisation.

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Section A When Where the incident occurred
Time of Incident
Date Of Incident
Ward / Department e.g. Ward 1, A E
Name of hospital e.g. MREH, or offsite location
e.g. patients Home
Exact Location specific location of incident
e.g. Bathroom. Bed bay
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Section B - Who Was or could Have been affected
Complete Section if staff involved
Complete Section If Patient involvement
Complete section if Other
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Section C Was anyone else involved in the
incident
Complete Section if staff involved
Complete Section If Patient involvement
Complete section if Other
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Section D What type of incident was it.
Decide on cause from the list of cause groups in
table 2 (grouped to assist selection)
Enter Severity Level from Table 1 (see next
slide) and also add a N if incident was a near
miss
Did a fatality Result from the incident
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Severity Levels
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Section D What type of incident was it.
Decide on cause from the list of cause groups in
table 2 (grouped to assist selection)
Enter Severity Level from Table 1 (see next
slide) and also add a N if incident was a near
miss
Did a fatality Result from the incident
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Incident Causes

• To get great in-depth analysis of types of
  incidents occurring with trust new incident
  cause groups established (handout).

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Section D Type of Incident (Cont)
Extra information regarding Injury type of
injury e.g. cut/laceration, burn, etc. Body
Part e.g. Back, Leg. injury location e.g.
left or right.
Did an injury (clinical or none clinical) result
from incident if yes fill in extra information,
If no advance to next section
Was any treatment given following incident if so
please tick what treatment was administered and
by whom.
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Section D Cont
Was the Medical Device quarantined after incident
Enter Type Serial No of device
Was Medical Device involved during the incident.
If yes, fill in extra information. If no, advance
to next section
Was the Medical Engineering Maintenance
Department informed?
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Section E What Happened

• Give BRIEF / FACTUAL Description
• Use short discrete sentences.
• Do not Make assumptions.
• Make Writing legible and avoid abbreviations
• If medication involved please state.
• If required use addition sheets for section E
  (attach securely to incident form)
• If there were witnesses please attach names and
  details on additional sheet (attach securely to
  incident form).

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Section F Immediate Action

• What actions were taken to make the situation
  safe (including actions taken to make any person
  condition safe)?
• Communicate events to all relevant people (inc.
  staff, line management, relatives patients).
• use same criteria as section E

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Section F Immediate Action (cont)
Event recorded in Health Record
Was the Patient / Relatives Informed of the event
If the Parent / relative was not made aware of
event please state why
Were the police involved with / as result of the
incident?, if yes please tick enter crime
number given
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Section G Person completing form
Person complete the form first and surname (no
DOB required!!)
Contact telephone no.
Date incident form completed
Reporters status (if staff please complete, which
department employed by designation)
Please sign incident form here
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Incident report procedures

• Once incident has occurred and immediate actions
  taken to ensure safe situation.
• Fully Complete Incident form.
• Hand copies (both copies any addition sheets)
  to risk / line manager according to local
  structures.
• If incident reporter is unable/unwilling to pass
  completed Incident Reporting Form to risk / line
  manager --- forward completed Incident Report
  Form to the Risk Management Department with a
  note expressing the confidential desire.

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Practice Example

• Please think of an incident that you have been
  involved in or imagine a incident scenario and
  try completing an incident form for this
  occurrence.

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Section H Risk / Line Managers
Was any staff member absent from any duties
following incident? Please indicate length of
(potential) time off please confirm absence
time with Health and safety adviser when known)
Risk / line managers First Name Surname
Action required. What further action is required
following report of incident?
What was the severity of outcome (actual impact)
according to Severity table 1
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Incident form Next steps (risk line managers
responsibilities)

• Send top copy of fully completed incident form (
  addition sheets) to the Risk Management
  Department, 1st Floor, Post Grad Centre, MRI.
• File 2nd Copy as departmental protocol (e.g.
  Health record, personal file if and when
  appropriate)

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Action Required

• Low level investigation (usually conducted on
  level 1 2 incidents) make sure immediate
  action has made immediate situation safe.
• Examples of investigations - looking at
  likelihood of re-occurrence, if possible
  underlying causes, if a trend is emerging
  regarding incident, etc.
• Document in Monthly Reports

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Root Cause Analysis

• Levels 3,4, 5 require root cause analysis of
  the incident. (however levels of the
  investigation will depend upon the serious /
  complexity of the incident)
• Root cause analysis investigation cover sheet to
  be completed and sent to RM.
• The Risk Management Department provides in-depth
  RCA training (Contact Julie Wan 276 5144)

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Feedback / Actions Taken

• Individual Incidents.
• Document in Monthly Patient Safety Reports
  emailed to Clinical Gov. Group and displayed in
  the clinical areas
• Risk Management / Clinical Governance (local /
  Trust wide level).

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Measuring Pilot Objectives

• Staff Questionnaires (all aspects of the incident
  reporting process)
• Audit of incident forms.
• Risk Database capture time.
• Recordings of general opinions.
• Training course evaluation.