Download Guidance on reporting an adverse incident

NHS Dorset Clinical Commissioning Group
Guidance on reporting adverse incidents
1.
Purpose
1.1.
The purpose of this guideline is to describe the types of incidents that may be
encountered in nursing homes/residential homes, and the actions required to
ensure that the incident is reported appropriately.
1.2.
It is important to ensure that all incidents are reported correctly and in a timely way
so that areas of risk can be identified, and actions can be taken to prevent
recurrence.
1.3.
The CCG is not concerned with apportioning blame, only preventing the occurrence
and recurrence of adverse incidents.
2.
What type of incidents should be reported?
2.1.
This guideline covers types of incidents. The following list contains some examples:
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drug errors in GP prescribing, errors in preparation and dispensing in
pharmacies;
administering medication resulting in harm to residents;
adverse drug reactions (ADRs);
issues surrounding medication on discharge, e.g. where the residents own
medication is not returned with the resident, or no take home medication is
provided;
need to perform resuscitation on patients;
failure of medical equipment used to deliver clinical care;
accident due to equipment or supplies defect;
delay in obtaining patient medical records/missing medical records on
transfer from hospital or community care;
incomplete information on discharge from hospital
delay in obtaining results for patients resulting in harm, e.g. blood results
from hospital;
unexpected death;
outbreak of infection or isolated case of infection and notifiable diseases;
wrong or missed diagnosis resulting in patients harm;
patients developing DVT or PE within 2 weeks of discharge from hospital;
accident due to equipment or supplies defect;
injuries to staff i.e. those reported under RIDDOR;
injuries to residents and visitors resulting in admission to hospital;
near misses with the potential to have serious consequences’;
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violence and aggression (including, verbal abuse, threatening behaviour and
physical attacks, resulting in serious harm);
patient safety incidents (including grade 3&4 pressure ulcers whether preadmission from a community setting or post admission from a hospital
admission;
breaches of confidentiality
not receiving adequate supplies of continence products on discharge from
hospital
any incident resulting in the activation of the Business continuity plan
Issues relating to the provision of access to Health & Social Care (Dentist, OT
Physio or CMHT)
2.2.
This list is not exhaustive – there may be other occasions where it is appropriate to
report.
3.
Process for reporting
3.1.
All clinical and non-clinical incidents occurring in the home should be reported using
the “Significant Event Incident Form” (see appendix A).
3.2.
The incident should be reported as soon after occurring as practicable.
3.3.
The form may be posted to the following address:
Avril Brown (Mrs)
Patient Safety & Risk Facilitator
Vespasian House
Second Floor, West Wing
Bridport Road
Dorchester
DT1 1TS
Appendix A
SIGNIFICANT EVENT INCIDENT FORM
Residents details
Patient name
Identifying number on system for patient:
NHS No. (if known)
Hospital No. (if known)
Date of Birth
Male or Female
Ethnicity of patient (if known)
Name of resident’s GP
Incident details
Date of incident
Time of incident
Date of reporting
Reported by
Job title
Name of Nursing home
Address
Description of incident Record fact and not opinion. Include a description of any medicines
involved / injuries sustained / equipment problem / tests given.
Persons involved (witnesses or attending staff)
Person 1
Person 2
Person 3
Name
Status
Job title
Additional considerations
Does this incident involve controlled drugs?
Yes
No
Does this incident have vulnerable adult issues?
Yes
No
The forms can be sent in hard copy to Avril Brown, Patient Safety and Risk Facilitator, Quality and
Directorate, Vespasian House, Bridport Road, Dorchester, DT1 1TS
November 2013
3
SIGNIFICANT EVENT INCIDENT FORM
Severity (what happened today) – see Risk Matrix below
White (Near Miss)
Prevented
No harm
harm
Minor
Green
Serious
Yellow
Major
Red
Death
Red+
Risk Matrix
Severity
Impossible
0
Prevented Harm – 0
No Harm (Near Miss) – 0
Minor -1
Serious – 2
Major – 3
Fatality – 4
Multiple Fatalities -5
Rare
1
Green
Green
Likelihood
Unlikely
Moderate
2
3
Likely
4
Certain
5
Green
Green
Yellow
Yellow
Green
Yellow
Yellow
Red
Red
Green
Yellow
Red
Red
Red
Green
Yellow
Yellow
Red
KEY:
Low Risk
White
Moderate Risk
Green
Significant Risk
Yellow
Actions taken
Signature
Date
4
High Risk
Red