Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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: 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’; 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