| Author: | Jono Erodotou |
| Responsibility: | All Staff |
| Effective Date: | 01 June 2024 |
| Review Date: | 30th May 2025 |
| Approved By: | |
| Version Number: | 01 |
Amendment / Review History #
| Date | Author | Comments |
|---|---|---|
Purpose #
The purpose of this policy is to make clear the incident reporting and investigation process, from incident recognition through to completion of the actions and closure.
If the policy is implemented successfully, the result will be:
▸ Continuous reduction in levels of harm.
▸ The provision of a safe environment for staff, patients, visitors and contractors.
▸ All incidents and near misses reported and investigated in a timely manner and appropriate learning and actions taken as a result.
▸ To ensure that the company complies with current legislation.
Successful implementation of this policy has the overarching aim of reducing patient harm and improving safety for patients, staff/contractors.
Duties #
The Ops Manager / CQC Manager
The Ops/CQC Manager will receive information on incidents via online system. This is in order to seek assurance that internal controls are in place and are operating effectively in relation to incident management and safety improvement.
The Ops/CQC Manager, has overall responsibility of the risk management, including the management of incidents.
Data Protection Officer
The Data Protection Officer (DPO) is a statutory role for all public bodies. They are required to monitor compliance to data protection legislation and compliance with data protection policies. This includes managing internal data protection activities, of which incident reporting is a crucial part. They also provide the link between the organisation and the Information Commissioners Office (ICO) to ensure that there is effective cooperation and cohesion.
Heads of Departments and General Managers #
Heads of departments and general managers are responsible for the provision of care, or portfolio of work, within their allocated designation. They are responsible for ensuring that an investigation into any incident is conducted in a timely manner and to a high standard, in order to ensure that actions are taken to prevent a recurrence.
The ownership of an incident or near miss sits with the head of department, general manager, or relevant equivalent. These managers are responsible for overseeing the investigation process and to provide guidance and support to any manager they may have delegated the investigation to.
The head of department, general manager, or equivalent, in the area in which the incident occurred is responsible for assigning an appropriate investigating officer and ensuring sufficient time for the investigation is allocated. They are responsible for ensuring that the investigation follows due process and that the conclusions drawn are sound and accurate. They are also responsible for ensuring learning is disseminated and shared.
The head of department or general manager is also responsible for implementing Duty of Candour discussions with patients and their families, supporting the investigating officer.
All Staff / Contractors #
All staff / contractors working for K4 Medical Services share the responsibility of reporting incidents and near miss. Staff / Contractors will be empowered to report events or occurrences which they feel is an incident, some examples of which can be found at Appendix 1. Staff / Contractors will report such concerns via the online system as soon as possible, ideally within 24 hours of the incident occurring. If staff / contractors are concerned in relation to a possible serious incident, this should also be identified to the manager on duty on that shift via duty phone. Supporting documentation must be passed on without delay.
Staff involved in an incident or near miss are required to fully participate in an investigation openly and honestly, in order to assist with establishing the facts and the reasons for the incident, and to identify ways in which lessons can be learned to avoid recurrence.
Definitions #
Adverse Incident –
An adverse incident can be described as anything which occurs away from the intended course of action, which may or may not have resulted in harm occurring.
Some examples of incidents which should be reported on the online form are as follows:
▸ A Patient becoming physically or verbally aggressive towards a staff / contractor.
▸ Patient given the wrong dose of a medication or via the incorrect route.
▸ Staff member injures themselves whilst undertaking a manuel handling procedure.
▸ Confidential staff / contractor or patient information misplaced.
▸ Equipment malfunctions during a patient care episode.
This is not an exhaustive list. A more detailed list (but still not exhaustive) can be found at Appendix 1.
Report –
An incident that does not meet the national criteria to be reported as an SI, that does present an opportunity for organisational learning by detailed examination. This is good for identifying good practice as well as missed opportunities and lessons to be learned.
Near Miss –
An incident which has the potential to cause harm but careful management has prevented the incident. For example, a slippery floor where no signs have been laid out but resolved prior to a slip, or a delayed ambulance attendance where the patient does not come to harm.
RIDDOR –
Is law that requires employers, and other people who are in control of work premises, to report and keep records of:
▸ work-related deaths
▸ serious injuries
▸ cases of diagnosed disease caused by work activities
▸ certain ‘dangerous occurrences’ (near miss incidents)
Further information is available at www.hse.gov.uk/riddor
Serious Incident –
Serious incidents in the company and NHS work include acts and/or omissions occurring as part of NHS-funded healthcare that result in:
▸ Unexpected or avoidable death of one or more people
▸ Unexpected or avoidable injury to one or more people resulting in serious harm
▸ Unexpected or avoidable injury to one or more people that requires further treatment by a healthcare professional to prevent death or serious harm
▸ Actual or alleged abuse during the provision of NHS-funded care
▸ Never events (see NHS England Never Events Framework)
▸ Significant data breach
▸ Loss of public confidence in the service
Incident Reporting and Management Process #
Key timeframes within the incident management process and who is responsible:
▸ Incident or near miss should be reported on line as soon as it is and practical to do so.
▸ An manager should be assigned as soon as is practical after the incident is reported online to review
the incident and take immediate action to ensure the safety of staff / contractor and patients. In any case, an manager must be assigned within five calendar days of the incident being reported.
▸ Duty of Candour to be discharged as outlined in the Duty of Candour Policy for further information.
▸ Investigation completed within 35 calendar days of the incident being reported.
▸ The investigation reviewed and finally approved within five calendar days of investigation completion.
Incident Reporting
Incidents must be reported by the staff / contractor who witnessed it. When more than one member of staff or contractor witnessed the incident, it need only be reported once. As such, members of staff or contractor should decide who reports it.
An incident must be reported online and no further consultation with a manager is required to do so. If the member of staff deems an occurrence to be an incident, it should be reported so a further examination can take place.
An incident report can be made by
▸ Online: LINK TO FOLLOW
If there is a need to take significant action following an incident to prevent reoccurrence, the reporter may decide to highlight this to the duty manager at the time in addition to reporting the incident online.
The incident report must include the following details (where know):
▸ Accurate incident date and time
▸ Accurate location of where the incident took place
▸ Accurate details of the people involved.
▸ A detail and factual account of what happened, including whether the reporter feels that harm was caused as a result of the incident.
Incidents relating to external organisations
Due to the nature of the work the company undertakes, staff / contractors have occasion to report incidents and near misses relating to other provider organisations, including hospitals, care homes and care agencies. These incidents are reported on the Companies incident reporting system in the same way as an internal incident.
As these incidents relate to another organisation, it is not possible or appropriate for the Medicore Ambulance Services to conduct the investigation. Our responsibility is to notify the provider organisation of the details of the incident and to share the necessary details to enable them to conduct their own investigation. This can be done in several ways:
▸ Email (via nhs.net account) to the relevant department at the provider organisation. (When available)
▸ Telephone to the provider organisation’s PALS department (document in the incident report)
▸ Via external organisation notification letter
Once this has been passed to the relevant organisation, it is appropriate to close this incident report, providing feedback to the reporter that it has been passed to the correct organisation for their investigation. If feedback is received from the other organisation, this should be attached to the report and shared with the staff / Contractor at the later date.
Duty of Candour
The Company is statutorily required to implement the Duty of Candour for appropriate cases as per the Health and Social Care Act, 2008, Regulation 20
For further information about the Duty of Candour, please see the Duty-of-Candour
Outcomes and Learning
Following completion of an investigation, a conclusion must be reached. The Company advocates the principles of fair blame as part of its just culture and recognises that in many incidents, the root causes of errors are based in process and system errors. The incident management system therefore works on the premise that investigations are conducted in a non-punitive and supportive manner, unless it is determined that a member of staff has knowingly acted in a reckless, intentionally unsafe, or criminal manner.
Potential outcomes for individual staff involved:
▸ Discussions about the case and the raising of awareness with regards to how the incident can be avoided. This includes reference to relevant policies, procedures and guidelines.
▸ Additional Training
▸ Clinical debrief
▸ If the investigation evidences deliberate, unsafe, or criminal acts, referral to the relevant HR process and referral to relevant professional regulatory body (HCPC/GMC/NMC), or the police, if appropriate.
The investigating officer must determine whether the incident is likely to be an isolated occurrence related to the patient or individual staff involved, or whether there is a likelihood of recurrence. In this instance, learning should be shared more widely to minimise recurrence. This can include:
▸ Memos to staff within the team.
▸ Team Training
▸ Amendments to local processes (within the frameworks of K4 Medical Services policies and procedures.)
Feedback to Staff
Ongoing contact with the member of staff or contractor reporting the incident throughout the course of the investigation is important, in order to ensure involvement of the relevant persons in the investigation.
Upon completion of an investigation, when the incident has been finally approved. A copy of the report with feedback is to be sent to reporter. This ensures that feedback is always given. If a secure email address has not been provided, the investigating officer should seek contact with the reporter, and give feedback manually if desired.
Equality Impact Assessment
K4 Medical Services has made every effort to ensure this policy does not have the effect of discriminating, directly or indirectly, against employees, patients, contractors, or visitors on the grounds of race, age, nationality, ethnic (or national) origin, gender, sexual orientation, marital status, religious belief or disability. This policy will apply equally to full/part time employees and contractors.
Appendix 1 – Example incidents and near misses (not exhaustive) #
Examples of adverse incidents, near misses and other hazards affecting clients, staff, contractors or members of public:
▸ Slips, trips falls and collisions
▸ Healthcare associated infection
▸ Incorrect treatment (e.g. failure to defibrillate when indicated)
▸ Any event which results in restraint of a patient by ambulance staff/contractors, regardless of section status or presence of other services
▸ Medication errors (e.g. wrong drug, incorrect dosage, incorrect time administered, contra indications to drugs not assessed etc)
▸ Adverse reaction to medicines
▸ Accidental injury to a patient or client (e.g. damage to patient’s foot during transfer)
▸ Accidental injury to employee or contractor or member of public arising out of work activities.
▸ All road traffic accidents involving company vehicles or vehicles used for company activities on and off K4 Medical Services premises
▸ Inoculation, needle stick or sharps incidents
▸ Self-harm incidents
▸ Contact with moving machinery or electricity
▸ Manual handling incidents (including musculo-skeletal injuries)
▸ Physical or verbal abuse or threatening behaviour
▸ Medical device or equipment failure
▸ Contact with harmful or hazardous substances
▸ Client, contractor or staff use of alcohol or illicit drugs on K4 Medical Services premises
▸ Theft, loss or damage to client, staff, contractor or company property
▸ Clinical waste and general waste incidents (including spillage of hazardous substances, inappropriate segregation, labelling of waste
▸ Delay in diagnosis, wrong or incomplete diagnosis or in contact patient assessment
▸ Suspected or actual abuse of valnerable adults
▸ Unplanned release of hazardous substances into the environment
▸ Dangerous occurrences that require reporting under the RIDDOR regulations
▸ Security incidents – involving people, property, equipment and informations
▸ Adverse incident involving contractors and sub contractors e.g. failure to observe safety rules, poor attitude etc
▸ Data protection breaches or breaches of confidentiality
