An adverse incident is defined as 'any event or circumstance arising during NHS care that could have or did lead to unintended or unexpected harm, loss or damage'.
Information is collated on all reported incidents and 'prevented incidents' involving patients, staff and visitors, clinical and non-clinical care, confidentiality, consent, fire, security and any health and safety incidents.
If an incident results in a serious injury or an unexpected death, staff should immeditaely contact the Head of Clinical Governance & Patient Safety on x8185, or the Clinical Site Practitioner on Bleep 0313 out of hours.
The aim is that all completed Incident forms reach the Patient & Staff Safety Team within 5 working days. Information on the form includes any action being taken to investigate the incident, or action that has already been taken to resolve it.
The purpose of reporting incidents is to learn from them to reduce the likelihood of the event occurring again. Clinical units and corporate departments are responsible for putting systems in place so that they can follow up and learn from incidents that have occurred in their area - including incidents that are reported by other departments.
The P&SS Team are responsible for supporting and guiding this process.
Incident forms are available for download and can be emailed to the Patient and Staff Safety team.
Incident reporting
All incidents are reported using the Incident reporting form. These are then sent to the Head of Clinical Governance & Patient Safety, 6th floor, The Old Building. Staff are encouraged to report all incidents in order to gain a true idea of what trends may be occurring in the hospital.
Incident reporting flow chart
Open the Incident Reporting Process Flow-Chart in a new window.
Please refer also to the Incident Reporting Policy and the Serious Incident Policy, a more detailed explanation of the process and the grading system used can be found further down this page.
The Patient & Staff Safety Team will become involved in investigating any incident if it is Grade 4 or 5, and they should therefore be informed immediately if a serious incident occurs. They can also assist in any local investigation for less serious incidents and prevented incidents by offering advice and support where necessary.
However, it is primarily the responsibility of the local departmental managers to follow up with their staff and the family on incidents that have occurred. If having assessed the incident, outcome for the child/staff member and any contributory factors, no further action is considered necessary, this will be stated on the form.
Feedback
Feedback is given in the following ways:
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A breakdown of incidents per ward/clinical unit is collated every month by the patient and staff safety team, and sent to senior managers to promote open discussion and follow-up at unit level. The overall intention is to use information from reported incidents to identify which aspects of the service can be changed to improve safety. Managers who require this information or who would like to discuss specific needs should contact the Head of Clinical Governance & Patient Safety on Ext. 8185.
Every clinical unit or corporate department should have an agreed process for regularly reviewing incident forms. In many areas this is achieved through a Risk Action Group that meets monthly.
A member of the Patient & Staff Safety Team can attend these meetings if required. Any minutes from such meetings should be sent to the Head of Clinical Governance & Patient Safety.
Following these meetings, any issues that are identified as needing ongoing attention to resolve, should be added to the department's risk register with a timely action plan.
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In addition to monthly feedback to clinical units, summaries of incidents are sent to the following people, to read and take further action if necessary:
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Drug error incidents are sent to the pharmacy manager
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Pressure sore incidents are sent to the tissue viability nurse who researches pressure care
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Equipment errors are sent to biomedical engineering
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Blood test/blood transfusion incidents are sent to the Specialist Practitioner of Transfusion
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Resuscitation incidents are sent to the resuscitation officer
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Infection control incidents are sent to the infection control director and CNS
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Child protection incidents are sent to the named nurse
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Moving & handling incidents are sent to the moving & handling trainer
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Quarterly and annual reports
Contributing factors that can lead to incidents
When incidents are analysed, it is often found to be a sequence of events which lead up to an adverse event occurring. Below are examples of the types of contributory factors that have been identified.
Organisational & Management factors
Work environment
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Staffing levels and skill-mix
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Workload and shift patterns
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Design, availability and maintenance of equipment
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Administrative and managerial support
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Verbal communication
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Written communication and documentation
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Supervision and seeking help
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Team structure - including teamwork, leadershi
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Interruptions
Individual factors
Task factors
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Task design and clarity of task
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Availability and use of protocols
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Availability accuracy of test results
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Availability of records
Patient Factors
- Condition - complexity and seriousness
- Language and communication
- Personality and social factors
How is an incident graded?
5 Catastrophic - Unexpected death of one or more persons, national adverse publicity, potential litigation, major health and safety incident e.g. toxic gases, fire, bomb, catastrophic financial loss.
4 Major - Permanent injury, long term harm or sickness, involving one or more persons, potential litigation, extensive injuries, loss of production capability, health and safety incident, some toxic release, fire, major financial loss.
3 Moderate - Temporary injury, one or more persons, possible litigation, medical treatment required, health & safety incident, mod. financial loss.
2 Minor - Short term injury following incident, first aid treatment required, on-site toxic release immediately contained, minor financial loss.
1 Insignificant - Incident occurred but resulted in no injury, and no treatment required; no financial loss.
0 Near miss - Incident did not happen, but could have, if an intervention had not taken place; low financial loss.
Why is reporting important?
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Isolated incidents may seem trivial or of little consequence. However, the aggregated data may show certain trends which are impacting on your ability as a member of staff to provide the level of care you would like to for your patients.
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Reporting incidents promotes learning. When an incident occurs it is easy to feel you are the only person that this has happened to yet it is rare that something happens because of the action of one person. Sharing the experience enables us to look at the systems in which you work and the contributory factors which may have increased the likelihood of that event occurring.
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The sign of a good reporting system is one where the number of incidents reported increases, but their severity falls. This is an indicator that staff are identifying risks earlier, before they become more serious and feel able to report incidents without the fear of being criticized by other staff. This helps to build an open and fair culture.
Root Cause Analysis (RCA)
"Root Cause Analysis is a structured investigation that aims to identify the true cause of a problem, and the actions necessary to eliminate it" - Bjorn Anderson and Tom Fagerhaug
A Root Cause Analysis looks at the core principles behind an incident, and asks:
Structure of a Root Cause Analysis
After an incident occurs, it is graded to ascertain how serious the incident was. At Great Ormond Street Hospital we undertake a RCA for serious (ie Major or Catastrophic) incidents as this provides a structured way to ensure that the investigation is thorough. The first step is to collect a description of events from those involved and the environment in which they were working. This may take the form of:
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personal accounts (written or in interviews)
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policies and procedures relating to incident
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patient's records
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family account of incident
From this, a chronology of events is made. This is done by writing out a detailed timeline of events as they occurred.
View a simplified example of what a timeline should look like.
This helps to give an overview of what was happening at the time and to identify where there are any gaps in the information available
What happens next?
A meeting is arranged between all those involved to go through the time line. By discussing the event from start to finish, it is often possible to fill in any gaps.
This is why it is important to ensure that all relevant people are included. Often the first assumption as to why an event occurred is not necessarily correct and the discussion often highlights other activity going on which was not at first obvious. This can be a time consuming and, depending on the nature of the incident under discussion, a stressful experience.
The Patient & Staff Safety Team are experienced at using this technique and have a role in supporting staff through this process. Finding a suitable time and location for the meeting is important to avoid interruptions and ensure every one has a chance to air their views in a supportive environment.
Identify the Care Management Problems (CMP)
A care management problem is "an act or omission by staff in the process of care". This is rarely a deliberate act or omission but can occur because staff get interrupted, or the child’s condition may change etc. Examples of care management problems are:
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failure to monitor, observe or act
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incorrect (with hindsight) decision or action
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not seeking help when necessary
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failure to note faulty equipment
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not following agreed protocol
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incorrect protocol applied
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wrong treatment given
Techniques to discuss the CMPs
This involves taking a blank piece of paper, and writing down as many ideas as you can think of that had an impact on the incident occurring. It is often best done in small groups, then the information can be shared.
This involves asking the question why? to the reason for the adverse event, followed by asking why? to the answer to that question, etc. which should take you back in time to some of the core reasons why the events took the turn that they did. For example:
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Why did the aeroplane crash? Because it ran out of fuel.
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Why did it run out of fuel? Because it was not filled.
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Why was it not filled? Because the fuel technician was absent.
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Why was he absent? Because he overslept.
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Why did he oversleep? Because he was made to work a 14-hour shift the day before.
If you are interested in receiving training on the benefits and techniques of RCA, please contact the Head of Patient Safety on Ext. 8185, or book yourself on the 'Managing Incidents and Complaints' training course, booked through Personnel.
