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ACCIDENT & INCIDENT REPORTING
POLICY & PROCEDURE
October 200* (Human Rights Act Compliant)
February 200*, August 200*, May 200*
Adverse Incident Management Committee
POLICY AND PROCEDURE
This Policy and Procedure was
Formally approved by The Co.
on ......19 August 200*..........
Position ...Chief Executive …..
Issue No: Brd19080454
reviewed AIM May 200*
CONTENTS 1 INTRODUCTION 2 GUIDANCE ON REPORTING PROCEDURES 3 LEGISLATION 4 AIM 5 DUTIES 6 RESPONSIBILITIES SECTION 2 1 PROCEDURE: THE <COMPANY>S INTERNAL REPORTING ARRANGEMENTS 2 PROCEDURE: THE <COMPANY>S EXTERNAL REPORTING ARRANGEMENTS APPENDICES APPENDIX A (i) DEFINITIONS & GUIDANCE ON INCIDENT TYPES APPENDIX A (ii) ACCIDENT/INCIDENT FLOWCHART APPENDIX A (iii) INCIDENT REPORT FORM APPENDIX B CONTACT DETAILS APPENDIX C GUIDANCE ON RISK MATRIX APPENDIX D INVESTIGATING AN ACCIDENT/INCIDENT APPENDIX E RESPONSE BY PERSON IN CHARGE/MANAGER/SENIOR CLINICIAN AT TIME OF INCIDENT reviewed AIM May 200* 3 .
An untoward incident is defined as a deviation from a normal pattern of behaviour. which are capable of analysis. reviewed AIM May 200* 4 . Because of the nature of the <COMPANY> and the clients we treat there are a range of incidents. 2 GUIDANCE ON REPORTING i. The <COMPANY>’s Internal Reporting Procedure IR1 All incidents occurring regardless of damage or injury will be reported using the <COMPANY> accident and incident form namely. which need further consideration.1 INTRODUCTION There are statutory Regulations that require organisations to report accident and injury incidents and also inform relevant Government bodies of injuries and occurrences falling into some specified criteria as soon as practicable. In such cases the <COMPANY> has an additional policy and procedure for managing adverse incidents. these are generally referred to as Untoward and Serious Untoward incidents. Instructions on completion of the form are printed on the inner cover of the pad. In addition to these Statutory Requirements many <COMPANY>s/Trusts. treatment errors. ie telephone fax. incorporating the serious untoward incident policy which is also located in the General Policy Manual. including our own. The above reporting requirements and notification arrangements are described in more detail in Section 2. confidentiality issues. Within <COMPANY>s there are further mandatory requirements to report specific types of incident to other NHS and government bodies. Although this is a separate policy the completion of an IR1 incident form for such incidents is still a requirement under this policy and procedure. Pads of these forms are available from your head of department. The Chief Medical Officer in his publication ‘An Organisation with a Memory’ has spelt out the importance of organisations to learn from their incidents so that appropriate strategies are developed at both local and corporate levels. In serious untoward incidents further implications may ensue ranging from criminal damage. Each of these mandatory schemes requires the Primary Care Trust (<COMPANY>) to have accident/incident recording mechanisms. The IR1 form is the cornerstone of incident reporting within the <COMPANY> and its use is intended both for Clinical and Non Clinical incidents. The purpose of analysis is to enable remedial actions to be devised and implemented to reduce the number of incidents or the injury/damage occurring in any particular type of incident. serious damage or serious injury to individuals. or email. are members of self-insuring schemes such as the Clinical Negligence Scheme for Trusts (CNST) and the non-clinical liability arrangements. Risk Pooling Scheme for Trusts (RPST) of the National Health Service Litigation Authority (NHSLA). the IR1.
Clinical Incidents/Adverse Healthcare Events If any incident on an IR1 is deemed to be either a clinical incident/adverse healthcare event the Manager. which by its nature has the potential for Civil Action against the <COMPANY>.gov. Medicines Control Doctors.gov. Medical Devices In addition to completion of an internal IR1 form any adverse incident relating to Medical Devices has to be reported via a standardised return to the Medical Devices Agency. pharmacists and nurses are required to report any adverse drug reactions using the Yellow Card Scheme. model and asset/serial number(s) and this information should also be recorded on the incident report form at section F entitled “Outline apparent circumstances of incident including details of any equipment involved”.mca.us (with effect from 1 April 2003 the Medicines Control Agency will merge with the Medical Devices Agency and become the Medicines and Health Care Products Regulatory Agency (MRHA) www. The Pharmaceutical Adviser will be alerted to local prescribing adverse drug reactions through the <COMPANY>'s IR1 incident reporting procedure. in liaison with the Health & Safety Officer. This will be undertaken by the responsible manager concerned who will immediately advise Dr Brian Jones. Fire and Buildings Incidents Any Fire incidents or adverse incidents involving buildings or plant are also required to be reported to the NHS Estates via the Director of Corporate Affairs.us) A copy of the yellow card scheme guidance has been forwarded to each <COMPANY> nurse prescriber. should be immediately notified to the Director of Corporate Affairs who will then notify the National Health Service Litigation Authority (see Section 2. dentists. The record should state the make. the <COMPANY>'s Medical Devices Liaison Officer that a notification has been sent. 2(e)) or other appropriate legal body. in addition to completion of an internal IR1 form.ii. Food Incidents Any incident regarding food including foreign bodies. Guidance on the scheme can be accessed from the Medicines Control Agency website via www. incorporating serious untoward incidents. vi Incidents Liable to Civil Action Any incident. vii. will ensure that the Assistant Director of Clinical Governance is given details as appropriate for that officer to produce relevant reports and initiate investigations whenever necessary in accordance with the policy and procedure for reporting adverse events. v. A record of the equipment in use at the time of the incident is required. iii.mrha. reviewed AIM May 200* 5 . It is important that any faulty equipment is removed and secured immediately following any incident. iv. deterioration etc will also need reporting to the Local Environmental Health Department of the local council and to the Food Standards Agency.
(See Appendix B attached for contact details). Ensure statutory notifications are made within the prescribed time limits detailed in the legislation. 4 AIM This Policy has been developed in order to: 1.3 a LEGISLATION Report of Injuries Diseases and Dangerous Occurrence Regulations 1995 (RIDDOR) Requires the reporting of accidents of a specified nature to the Health and Safety Executive (HSE) using a standard form (F2508). 2. the <COMPANY> has dispensation from the completion of BI510 entries. It is well documented in Health and Safety management circles that in the majority of incidents system failures are the main causation. The reporting of diseases uses a slightly different form referred to as a F2508A. Dangerous Occurrences such as failure of lifting equipment.9 of the Risk Management Strategy & Policy. 3. Social Security Act 1975 This Act requires the reporting of accidents in ‘The Accident Book’. Reference should be made to the guidance if there is any doubt or alternatively contact the Health & Safety Advisor for advice. Note that following the adoption of the internal accident form IR1. 4. b. The guidance to the regulations has appendices.The <COMPANY> supports a fair culture. the <COMPANY> has a specific Speaking Out policy which sets out the procedure by which members of staff can speak out without fear of attributing blame. It is not the intention of this policy to attribute ‘blame’ of a personal nature. Ensure in the event of more serious incidents detailed investigation takes place to establish the facts of the incident and to further ensure. Describe the management arrangements for reporting of incidents and accidents. which list the types of injury. This is clarified under para 5. diseases and dangerous occurrence. which result in an absence from duty of 3 days or more. In addition. explosion. which need to be reported. scenes of incidents remain undisturbed should the relevant authorities become involved. reviewed AIM May 200* 6 . The most common report is for injuries to staff. The disease has to be diagnosed by a Medical Practitioner. and failure of supporting structures are also reported on the F2508A form. The aims of the policy are to identify these failures and implement remedial action to prevent reoccurrence. Assign duties and timescales for the reporting of incidents. which is a book of official forms referred to as BI510. which is an ‘Approved form’ (by the Department of Social Security).
normally 10 working days for F2508 forms. Directors The Directors. amputation etc. Supervisory Staff/Managers have a duty to instigate immediate action to prevent reoccurrence of the incident and to ensure appropriate treatment is organised for any injured persons. Alternatively the manager may notify the HSE direct and then inform the Health & Safety Officer as soon as practicable. Where the incident is such. They should also carry out investigation of the more serious types of incident or incidents with a high level of repetition. will ensure all staff within their sphere of control are aware of the need to complete the various formal report forms reviewed AIM May 200* 7 . Where the investigation is of a more serious incident a supplementary sheet should be used and a copy of this sheet should be attached to the IR1 form. The Health & Safety Officer has been designated for this role. The supervisor manager will initiate the incident report and as appropriate route this to their departmental senior manager who should ensure the form is correctly completed. eg death. broken bones. All staff must verbally report any accident. marking the risk matrix in Section B of the IR1 form as soon as possible after the event to show the seriousness of the incident. near miss or untoward occurrence to their supervisory staff or manager immediately after the incident occurred and complete an incident report form within 24 hours. The Health & Safety Officer must ensure the forms are completed correctly and ensure they are sent to the relevant office of the HSE in the prescribed timescale. (Appendix C refers). b. 6 RESPONSIBILITIES a. The Director of Corporate Affairs/Director of Mental Health/Director of Primary & Community Care/Director of Clinical Governance-Medical Director should be contacted immediately in the event of serious incidents to assist in or take over the investigation as appropriate. Diseases and Dangerous Occurrence Regulations 1995 require a named “ responsible person” on behalf of the <COMPANY> must report to the local office of the Health and Safety Executive (HSE). (See appendix Aii). This will involve that manager in consultation with the member of staff concerned. that immediate notification is required. through their managers.5 DUTIES The Reporting of Injuries. In cases of doubt any of the 4 named directors may be approached for further guidance as well as the Corporate Affairs Risk/Manager. the manager must notify the Health & Safety Officer by telephone or fax to enable the HSE to be so notified. (Appendix D refers). In practice this requires managers within their specific areas to ensure as appropriate the official notification forms (F2508) are completed fully and then sent to the Health & Safety Officer for onward transmission to the HSE. Chief Executive The overall responsibility for ensuring compliance with this incident reporting system lies with the Chief Executive and Directors of <Your Company Name>.
IR1’s. reviewed AIM May 200* 8 . c. The Corporate Affairs/Risk Manager will collate information from the IR1 forms and produce quarterly accident and incident statistic reports for discussion at the Risk Management Committee.. The Corporate Affairs/Risk Manager will ensure that the original IR1 forms are filed in a coherent manner such that individual forms can be readily retrievable in the event of litigation etc. which are clinical in nature or could be adverse in respect to the care and treatment of our clients and patients. for a period of five years. Delegated Responsibility – Director of Corporate Affairs The <COMPANY> delegates the responsibility for the day-to-day operation of the incident reporting system to the Director of Corporate Affairs/Director of Clinical Governance and the supporting team as follows: i) The Corporate Affairs/Risk Manager The Corporate Affairs/Risk Manager will ensure information on non-clinical. clinical or adverse healthcare events being reported on the IR1 forms is recorded and collated in a meaningful way to enable the Adverse Incident Management Group to monitor and keep under review. F2508 etc and undertake the basic investigation requirements (see instructions at appendix D to undertake root cause and analysis investigation) as follows: Establish the facts Analyse the findings Establish the immediate causes and any underlying causes Take short term remedial actions to prevent reoccurrence as appropriate Make recommendations to prevent reoccurrence in the medium to long term Monitor any adopted recommendations Make formal records of findings and remedial actions Depending on the seriousness of the incident the advice and/or involvement of the Health & Safety Officer will be sought. (The Adverse Incident Management Group is a sub-committee of both the clinical governance committee and the risk management committee). and that copies of completed incident report forms are readily available to individuals who have rightful access. the PEC the Board. The Corporate Affairs/Risk Manager will provide the Assistant Director of Clinical Governance with relevant data in respect of incidents. The Corporate Affairs/Risk Manager will ensure that the Health & Safety Officer has sight of all IR1 report forms.
including the monitoring of any necessary remedial action. The Health & Safety Officer will advise and assist where necessary in any investigation. Employees should report any hazards they are aware of or become aware of in the course of their work to their line managers/supervisors. Line Manager The <COMPANY> delegates general safety responsibilities to every line manager and departmental manager. Employees should report all incidents including near misses to their line managers/supervisor. v.ii) Health & Safety Officer The Health & Safety Officer will actively analyse incident report forms and inform management of any problems. The Corporate Affairs/Risk Manager will also ensure that the original IR1 forms after recording on the <COMPANY>’s risk management database. Assistant Director of Clinical Governance The Assistant Director of Clinical Governance will ensure information on clinical or adverse healthcare events being reported on the IR1 forms is reported to the Clinical Governance Sub Groups and thereafter to the PEC and <COMPANY> Board. The Health & Safety Officer will produce bi-monthly accident and incident statistic reports for discussion at the <COMPANY>’s Health & Safety Committee. It is their responsibility to ensure there is an adequate supply of the various blank reporting forms within their areas of control and they should ensure that the most appropriate person completes the forms in a business-like and neat manner. iv. iii. The Health & Safety Officer will be responsible for ensuring the statutory notification of those specified incidents to the HSE. are filed in a coherent manner such that individual forms can be readily retrievable in the event of litigation etc. The managers should act as the quality control for completed IR1 forms and should only forward satisfactorily completed forms to the Corporate Affairs/Risk Manager as soon as practicable. Employees Responsibility Employees must report all accident injuries to their line manager/supervisor. Should any hazard pose imminent danger to others all staff should attempt to reduce the risk of the occurrence by their direct action. Where managers perceive weaknesses in form completion it is their responsibility to ensure additional training/information is given to those individuals. ie removing obstacles reviewed AIM May 200* 9 .
spillages etc. (For specific guidance for managers is attached at Appendix E) reviewed AIM May 200* 10 .on pathways/roads. placing temporary barriers around holes.
To assist in its completion each pad of forms has definitions and completion instructions printed on the inside cover. ill health. property damage or near miss the <COMPANY> requires the completion in the first instance of its own internal document referred to as an IR1 (Incident Report Form attached at appendix A(iii)).SECTION 2 PROCEDURES FOR THE REPORTING OF ACCIDENTS/INCIDENTS OR ADVERSE HEALTHCARE INCIDENTS. if death or serious injury has occurred then staff must notify managers immediately (both verbally and in writing on an IR1 report form) in accordance with the serious untoward incident reporting policy and procedure. an IR1 form should be completed within 24 hours. Once staff have verbally notified an incident (immediately) to their manager. which may be completed in conjunction with an appropriate supervisor/manager. vandalism. This will enable the seriousness of any incident to be agreed on the risk matrix on the form as well as giving managers an awareness of events in their areas and to further act as a means of quality control on form completion. In any event the manager who has overall responsibility for an area should see the form prior to it being sent on to the Corporate Affairs/Risk Manager. Completion of the form should be by the most appropriate person in the area at the time of the incident. Whilst ideally this will be a supervisor or manager there may be circumstances where others may initiate the form. It is important for all incidents to be reported in a timely fashion to both local and central management. It should be noted that where death or serious injury has occurred the incident must be reported IMMEDIATELY both verbally and in writing on an IR1 report form in accordance with the <COMPANY>’s adverse incident and serious untoward incident policy and procedure. abuse. harassment. For further guidance on completion of the risk matrix under section B of the IR1 and the timescales by when this should be done please see appendix C attached. Ergo it is important for notifications to be made within the stated timescales to ensure no incident falls outwith the HSE timeframe However. theft. c. It should be noted that it is not always possible to have all the relevant facts to hand at the time of initially grading the incident. The current form has been designed to ensure that much of the completion is reduced to ‘cross boxes’ wherever possible. Appendix D details the steps to take regarding investigation of the accident/incident. The Senior Manager will then submit the completed IR1 report form to the <COMPANY>'s Corporate Affairs/Risk Manager ideally this will be within a maximum of one week of the incident. death. Early identification of hazards or potential hazards will not only effect reviewed AIM May 200* 11 . 1 a THE <COMPANY>S INTERNAL REPORTING ARRANGEMENTS Where any incident occurs such as accidental injury. b. Therefore the Adverse Incident Management Committee will undertake re-grading of incidents following the implementation of any remedial actions deemed necessary once the investigatory procedures have been concluded. violence. The form consists of an A4 double-sided document with several sections and a unique reference number pre-printed on it.
RIDDOR 95 In addition to our own internal IR1 form there are some incidents which. by nature of their seriousness. copy the IR1 form to the responsible Director lead for their attention. it will send a copy of the report to the correct enforcing authority. under cover of a memorandum. which involve an absence of more than three days beyond the day of the incident require an F2508 completing and sending to the Health & Safety Officer for onward transmission to the HSE. In these circumstances it may be more expedient for the managers in the area to carry out the immediate contact with the HSE via their Incident Contact Centre. Any reported clinical/adverse incidents will also be copied to the Assistant Director of Clinical Governance. If the incident has resulted in a member of staff having time off it is permissible to send the form in with Section D ‘Query’ indicated and for managers to follow up with the information when the total absence is known. NB If a member of staff is involved in a physical assault then the incident MUST BE reported immediately to the <COMPANY>’s Security Management Director (Mr David Fullard). amputations. The original IR1 report form will be retained by the Corporate Affairs Risk Manager. These incidents are notified to the HSE using an official form referred to as an F2508 for injury incidents and dangerous occurrences and an F2508A for diseases. Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR) to the Health and Safety Executive (HSE). and for regular reporting to the Board. irrespective of where in England. 2 THE <COMPANY>S EXTERNAL REPORTING ARRANGEMENTS a. have to be reported under the Reporting of Injuries. The Health & Safety Officer will be notified by the Corporate Affairs Risk Manager on receipt of the IR1. The <COMPANY>'s Corporate Affairs Risk Manager and the Assistant Director of Clinical Governance will use the <COMPANY>’s risk management software to produce quarterly reports for discussion in the appropriate risk management forums. Similarly if the incident is more severe. but will also lead to early identification of systems. In effect this means telephone or fax followed by the formal notification on the F2508 within ten days. The ICC allows reports to be made to one single point. as well as completing an F2508 form the HSE have to be notified as soon as practicable. broken bones. the Corporate Affairs/Risk Manager will. It is not the intention to reproduce the completion instructions contained in the RIDDOR 1995 Regulations in this procedure. Once a report is received by the ICC. The ICC. The Security Management Director will then undertake action as described within Statutory Instrument 3039/2002. is a joint venture between the HSE and LA s. For definitions on what is reportable please refer to the HSE Information Sheet. d. Managers should generally be aware that all incidents.the outcome and cost of any liability claims. Following extraction of data from the IR1 form onto the <COMPANY>’s risk management database. The Incident Contact Centre (ICC) was launched on 1 April 2001. eg death. reviewed AIM May 200* 12 . Health Services Sheet No 1 “The Reporting of Injuries. Diseases and Dangerous Occurrences Regulations 1995: Guidance for employers in the healthcare sector”. practices or equipment that could have an effect on staff and patient care. Wales or Scotland a company/organisation is located. e.
Guidance on the scheme can be accessed from the Medicines Control Agency website via www. Incident Contact Centre. The MDA's address is as follows: <address> d. Scawby House) contact should be made with the Director of Corporate Affairs. Full completion of section F giving full details of the equipment involved at the time of the incident on the <COMPANY>’s IR1 report form will ensure this is recorded. the injured person and the accident.xxxx. model and asset/serial numbers. Caerphilly Business Park.us or alternatively link ia the HSE website 0845 300 9923 By Fax (charged at local call rate) 0845 300 9924 By email. This is because a record of the equipment in use at the time of an incident needs to be maintained stating the make. NHS Estates Managers and staff should also be aware that the <COMPANY> has several other requirements to notify other agencies of particular incidents of a specific nature. plant and non-medical equipment reports are required to be made to NHS Estates at the following address: <address> Managers having such incidents within the community should contact the Transport & Facilities Manager with all the relevant information to enable completion of an appropriate report form. buildings. A follow up of the initial report will be required in writing within 10 days by completing and submitting an accident report form (F2508).Contact details as follows:Caerphilly. Cedars.us (with effect from 1 April 2003 reviewed AIM May 200* 13 . b. Medicines Control Agency Incidents relating to adverse drug reactions are reportable via the Medicines Controls Agency yellow card system. Dr Brian Crompton. For internet reports: www. c.gov. Immediately a notification is sent to the Incident Contact Centre. CF82 3GG. Medical Devices Agency Any incident relating to medical equipment should be notified immediately to the relevant Cluster Lead/ the Assistant Director Primary & Community Care . For incidents relating to Fire. The Health & Safety Officer will liaise with the Corporate Affairs/Risk Manager and ensure a copy of the F2508 notification is placed on file with the original IR1 report email@example.com. For incidents within the headquarters site (Health Place. the <COMPANY>'s Medical Liaison Officer will need to be advised that a formal notification has been made to the Medical Devices Agency and will review the outcome.com The HSE will require brief details about the business.Clinical Services/Director of Mental Health before notifying the Medical Devices Agency on line.gov. managers should also inform the Health & Safety Officer and continue to route the formal F2508 notification to the his/her office.
The address and telephone number of the Local Environmental Office is as follows: <address> The Address of the US Food Standards Agency is as follows: <address> reviewed AIM May 200* 14 . NHSLA Incidents where there are likely to be civil claims required. Managers should inform the Director of Corporate Affairs of such incidents supported by the IR1 form to enable as much information to be gathered prior to reporting. be notified to the Local Environmental Office of the Local Authority and to the Food Standards Agency by the Modern Matron(s).gov. <address> f. to be notified to the National Health Service Litigation Authority as early as possible.us) A copy of the yellow card scheme guidance has been forwarded to each <COMPANY> nurse prescriber. e. in addition to being notified internally using the IR1 report form. where practicable.the Medicines Control Agency merged with the Medical Devices Agency and became the Medicines and Health Care Products Regulatory Agency (MRHA) www. Environmental Health Office Incidents relating to food will. The Director of Corporate Affairs will contact the Litigation Authority as appropriate.mrha.
Where staff do report directly to CSCI. it would be helpful if the Line Manager could be informed of this course of action in order to offer support. This should be discussed with the line manager at the time of completing the IR 1 <COMPANY> staff may also be informed of incidents which have occurred to patients/clients but which do not fit any of the above criteria. In cases where a member of <COMPANY> staff is aware of a pattern of injuries or where there is evidence of poor standards of care. it will probably be appropriate for the <COMPANY> to issue a standard letter to the Manager/Home owner to make them aware of the problem so that they can take the necessary action to prevent it reoccurring.Guidance for Incident Reporting in Registered Care Homes Primary Care Trust staff who visit patients/clients in registered care home settings should report the following types of incidents on the <COMPANY>'s Incident Reporting Form (IR1): incidents which involve members of <COMPANY> employed staff incidents which are witnessed by members of <COMPANY> employed staff incidents which involve equipment issued by the <COMPANY> (regardless of whether the incident was witnessed) In cases where <COMPANY> staff witness incidents. he/she should consider reporting this directly to CSCI or discussing their concerns with the line manager. The Commission for Social Care Inspection (CSCI) should be informed by the registered owner of incidents which happen in their home as part of the routine monitoring procedures. It should therefore be sufficient for a member of <COMPANY> staff to ask/prompt the staff within the home to record the incident if they feel it is warranted. reviewed AIM May 200* 15 .
dermatitis. Abuse or Harassment: Any incident involving verbal abuse. racial or sexual harassment or physical assault. or a sequence of events or omissions. Any event or circumstance arising during NHS care that could have or did lead to unintended or unexpected harm. loss or other damage to organisation or personal property. no matter how small. Health Care Near Miss: A situation in which an event or omission. environmental incidents (eg accidental discharge to drains or the atmosphere). incorporating the Serious Untoward Incident Policy. Please note that examples of definitions of adverse health care events are listed within the policy and procedure for managing and reporting adverse incidents. It should be noted that if an adverse incident is gauged as serious then the timescales and actions identified within the policy and procedure for reporting adverse incidents. For guidance on completion of the risk matrix please refer to appendix C attached to this document. etc). Ill health: Any case of known or suspected work or environment related ill health (eg infection. or unauthorised persons gaining access to. incorporating the Serious Untoward Incident Policy should be followed. Confidentiality/IT Incident: Any incident involving confidentiality or information technology systems which did or could have resulted in breach of confidentiality. whether or not as the result of compensating action. unsociable behaviour. reviewed AIM May 200* 16 .APPENDIX A i DEFINITIONS & GUIDANCE ON INCIDENT TYPES Adverse Healthcare Event (Patient Care): An event or omission arising during clinical care and causing physical and psychological injury to a patient. headaches. Near Miss: Any incident where under slightly different circumstances significant injury or loss could have occurred. false alarms. Violence. loss or damage. etc. ie any accident. Security. This does not include any incident caused deliberately (eg by act of violence or by fire) but would include road traffic incidents. Loss or Damage incident: Any untoward incident involving theft. arising during clinical care fails to develop further. or using systems. intrusions. Other: This type of incident should be marginal in number and might include accidental property damage or loss. thus preventing injury to a patient. NB a <COMPANY> "Loss of <COMPANY> Property form" should also be completed and forwarded to the Director of Corporate Affairs. NB The severity of any particular incident should also be indicated (by the person completing the form in consultation with their manager) on the risk matrix within Section B of the IR1 form. whether or not injury results. food safety/hygiene incidents. absconded patients and other security incidents (but not fire alarms). Theft. which did or could have adversely affected any person. Injuries to a person: A personal accident.
<YOUR COMPANY NAME> IR1 Incident Report Form Ref: APPENDIX Aiii Please note that WHERE DEATH OR SERIOUS INJURY HAS OCCURRED THIS SHOULD BE REPORTED IMMEDIATELY Please complete in BLACK ink and place a X in all relevant boxes. trip or fall. Abuse or Harassment to Staff Injury to staff of <COMPANY> Damage to <COMPANY> Equipment (Clinical) Injury to member of Bank/Agency/Temporary Staff Damage to <COMPANY> Equipment (Non-clinical) Injury to member of the public or visitor Confidentiality/IT incident Injury to contractor Security Incident Ill health of staff member or patient Near Miss Other (to be used if incident does not relate to any of the above. slip. WHEN AND WHERE DID THE INCIDENT OCCUR? (See guidance notes on how to complete) Location address: Secondary Location: enter Address. fall from height (specify height) physical assault etc (refer to pick list 1) 2. 2. First Aider. etc) None First Aid Occupational Health Seen by doctor A&E Advised see own GP Other (please specify below) Give details of attention received by the person. advice. Clinical/GP Surgery/other. 10. WHICH OF THE FOLLOWING BEST DESCRIBES THE INCIDENT? Adverse healthcare event (patient care) Violence. DID THE PERSON SUFFER PHYSICAL INJURY OR OTHER ADVERSE EFFECT? Yes If Yes give details below No/None apparent 1. Department. INCIDENT SEVERITY (to be completed by the line manager in consultation with incident reporter) Likelihood of incident recurring 1 2 3 4 5 Rare Unlikely Possible Likely Almost Certain Insignificant 1 □ □ □ □ □ Minor 2 □ □ □ □ □ Consequence Moderate 3 □ □ □ □ □ Significant 4 □ □ □ □ □ Very High/ Principal 5 □ □ □ □ □ C. What was the apparent cause of injury or adverse effect? Eg lifting patient. DETAILS OF ANY INDIVIDUAL AFFECTED BY THE INCIDENT Surname: First Name: Address: Post code: NHS or Staff No: Sex: M F Date of Birth: Was the staff member absent from duties? No of Hours absent RIDDOR reportable? Yes Time of Incident (24 hr clock) H H M M : Y IDENTIFY THE TYPE OF PERSON AFFECTED Patient/Client Visitor Contractor Staff Other If staff give Occupation Full or Part time? Yes No Query No Consecutive Days absent No E. etc Exact Location: Date of incident (eg.What nature of injury was sustained? Abrasion Fracture Bruising/Swelling Burn/Scald Laceration Sprain/Strain Both Trunk Not applicable Wrist/Hand Leg/Knee Shoulder Arm/Elbow Fingers Hip Ankle/Foot Toes Needle stick injury Electric Shock Multiple Injuries Musculoskeletal injury Amputation Asphyxiation Pressure sores Other G. DID THE PERSON RECEIVE ANY ATTENTION? (eg treatment. exposure to harmful substance. to be completed by either Doctor. Nurse or other person: Signature of Person giving assistance:(if appropriate) Date F. Record FACTS not opinions A. . or designation if staff) 1. WHERE APPLICABLE IDENTIFY ANY WITNESSES (Name and contact Tel No. counselling.06. Which part of the body was affected? Left Right Multiple Eye injuries Head Neck Face Back 3.05) D D M M Y D. Please ensure a clear description of the incident is recorded at Section H) B.
reviewed AIM May 200* 19 .
1 2 Nature of incident Verbal abuse 3 Threat of violence Contributory factors Drugs/alcohol Angry during 1:1 counselling Argument with other patient/client Disagreement about care programme In/out of seclusion Other (please specify) ii) Action taken: Successful Restraint De-escalation iii) Details of Alleged Assailant/Aggressor Name: Person class: Staff 4. Given rapid Tranquilisation Seclusion Male Patient/Client Visitor Contractor <COMPANY> Lost Property Proforma Completed Yes Female Other No Money Other Credit Cards Estimated Value: £ Vehicle Medical Equipment Other Computer Equipment Estimated Value: £ Vehicle Breaking and entering Burglary Petty Theft Fraud Robbery Other No Other Signature of person completing IR1 Form To whom reported 4 Details ie Crime Ref No Unobserved Yes Falls risk assessment completed ? No Chair Other Wheelchair Personal Clinical Factors Factors PLEASE WRITE CLEARLY Print Surname Date Reported 20 Commode Staffing Levels Signature of Head of Department/Service/Cluster Lead . PLEASE GIVE THE FOLLOWING ADDITIONAL INFORMATION I) Fatality – give date of death D Needle sticks/Sharps Clean Needle/sharp? Method of injury Transporting Re-sheathing Use 3) Violence/Abuse/Harassment D M M Y Y Y Y 2) Yes No Disposal (Sharp Bin) Disposal (improper) Handling waste Other (give details) i) Type of violence/abuse/harassment (see guidance notes) Please mark a X in the appropriate box.H. OUTLINE APPARENT CIRCUMSTANCES OF INCIDENT Description of equipment if involved: Make: Sent for repair? Yes No MHRA/Estates notified? Yes Model: Withdrawn Yes from use? Date of notification: No Serial No: Retained for inspection No Yes No I. WHERE APPROPRIATE. Adverse Health Care Event Select from Pick List 2 6. OUTLINE ANY REMEDIAL OR OTHER ACTION TAKEN FOLLOWING THE INCIDENT (Brief details) J. or force used). or knees. Patient Fall Observed Falls monitoring sheet submitted Was it a Fall From Bed Trolley Contributory Factors Environment reviewed AIM May 200* 5 6 Actual Physical Violence Sexual assault Objecting to personal care given Objecting to taking medication Response to staff requests Response to staff restraining Persecutory delusions Attempting to leave Command hallucinations In pain (physical) Escorted/Assisted (standing) Full restraint (on floor. Loss or Damage Personal Property Handbag/Purse Clothing Trust Property Drugs/Medication Linen Cause of Loss Vandalism Car Crime Were police involved? Yes 5. Security Theft.
whether or not injury results. using block capitals where possible. Complete the secondary location box. Section A Place an X in one box only to define the incident type. Near Miss: Any incident where under slightly different circumstances significant injury or loss could have occurred.Injuries to a Person: Any personal accident. specify treating Health Centre or Clinic in secondary location box and give the patient’s home address in the location address box. No deviation from the pick lists should be made. reviewed AIM May 200* 21 . Confidentiality/IT Incident: Any incident involving confidentiality or information technology systems which did or could have resulted in breach of confidentiality. loss or other damage to organisation or personal property. If the person is a member of Staff/Student/Trainee. Loss or Damage Incident: Any untoward incident involving theft. Otherwise. Any equipment involved in the incident should be retained untouched and in safe keeping for examination. absconded patients and other security incidents. Section I Complete the boxes to briefly describe any remedial or other action taken or proposed. no matter how small. specify their occupation and grade.g. i. etc). whether they are full or part time employed and whether they were or will be absent from duties. any person who suffers or potentially suffered injury. indicate the events leading up to the incident and the part played by any person(s) in the sequence of events. If absence is unknown. In the case of personal injury. etc. Violence/Abuse/ Harassment: Any incident involving verbal abuse. For example. dermatitis. The IR1 form should be completed stating where the incident happened by the member of staff who is first to know about the incident. Violence/Abuse/Harassment cross the box relevant to following: 1 Verbal abuse – vehement affront personally directed/minor damage to property. NOT OPINIONS Section C Please give location address where the incident actually happened. the person may be seen by a Doctor and sent to Occupational Health or advised to see his or her own GP.g. Please take care always to ensure that the correct boxes are crossed and where a text entry is required. middle stairs etc). 3 Attempted assaults 4 Assaults without injury 5 Assaults with minor injury 6 Assaults with injury needing medical attention or time off work. Section G Specify the names and contact numbers or designations if members of staff. treatment error.) might be involved.g. If the incident involves theft of personal property. for any witnesses to the incident. The Head of Department/Service signs the form to confirm all appropriate remedial action has been undertaken.g. In the case of violent/aggressive incidents complete a form for the injured person(s) only and complete the details of the aggressor on that form not a separate form. and the exact location box. They should also indicate the managerial person to whom they reported the incident with the date. Section H Give brief details of the circumstances of the incident. specify the details requested with reference to the pick lists. then go to Section G. Ill health: Any case of known or suspected work or environment related ill health (e. e. The following definitions apply: Adverse Healthcare Event: Any incident directly related to patient treatment or care. Theft. If any property/equipment is involved in the incident. give full details and complete a ‘Loss of Trust Property’ form. Complete separate IR1 forms for each person affected. State left or right side or both. Be clear about the part of the body affected. false alarms (but not fire alarms). etc). intrusions. put an X in the Query box. both eyes. Manager to complete RIDDOR reportable box. Section B This box should be completed by the line manager in discussion with the incident reporter. give details and complete boxes to include serial numbers as applicable. Section J Complete appropriate sections by placing X’s in the appropriate boxes in the section which best describes the incident. by act of violence of by fire) but would include road traffic accidents. Section D The individual affected by the incident is the person who suffers or potentially suffers injury or loss (including theft and any other property damage or loss). left hand. including flying or falling object Exposure to radiation Exposure to or contact with a biological agent Exposure to or contact with a harmful substance Struck by a moving vehicle Contact with moving machinery/equipment Exposure to fire/explosion Road traffic accident Self harm Unknown Pick List 2 Adverse Healthcare Event Wrong diagnosis made Failure to recognise complication of treatment Improper delegation to unsupervised junior Failure to warn (informed consent) Failure to follow-up arrangements Medication errors Infusions problems Problems with medical records Lack of adequate facilities/equipment Equipment malfunction Self harm Injury/harm to others by patient Incident in community from absconded/discharged patients Unexpected death Problems with blood/fluids Tooth injury cases and patient positioning problems Guidance Notes for completing IR1 Forms General Use the IR1 form to record ALL significant incidents. furniture. State NONE if there were no witnesses to the incident. medical equipment failure. Place an X in one box only to indicate the severity of the incident.g. right foot. The form should be passed to the supervisor/manager who should take responsibility for any incident investigation. Completing the IR1 form does not constitute an admission of liability of any kind on any persons. light.g. which did or could have adversely affected any person. For an incident occurring in a patient’s home (not a community home). WHERE DEATH OR SERIOUS INJURY HAS OCCURRED THIS MUST BE REPORTED IMMEDIATELY. unsociable behaviour. Please use a ballpoint pen to write clearly. For 3. The exact location box can be used to describe where the incident happened in some detail (e. specify the name of any substance(s) involved. temperature.g. fittings etc) Struck by a moving. RECORD FACTS ONLY. or unauthorised persons gaining access to. This does not include any incident caused deliberately (e. Please complete a separate form for each person directly injured or affected by the incident. indicate what the person was doing at the time and whether environmental factors (e. racial or sexual harassment or physical assault. 2 Threat – offering violent intent and directed personally/major damage to property. or using systems. ill health or loss. headaches.e. Section E Place an X in one box to identify any attention received by the person directly involved in the incident. Pick List 1 Cause of Injury Patient lifting/handling/carrying Lifting/handling/carrying (not involving patient) Patient absconding Contact with needle or other sharps Slip. etc and if fingers or toes are injured specify which one(s). Other: Incidents that do not fit into any of above definitions eg food safety/hygiene incidents. give brief details of any first aid or other treatment/attention received. Administrative Details The person completing the IR1 form should sign and date the form and print their surname in the space provided. toilet. by lift in main corridor.Section F If the person did not suffer physical injury or other adverse effect. which did or could have resulted in adverse outcome (e. that the correct choice is made by the carefully choosing from the pick lists provided. infection. please put an X in the NO box and complete question F1. trip or fall on the same level Fall from height Physical assault by a patient Physical assault by any other person Cut with sharp material or object (not sharps) Contact with hot or very cold surface or object Contact with electricity Struck against something (e. Record only known facts – not opinions. Where possible. Security.
reviewed AIM May 200* 22 .
APPENDIX B CONTACT DETAILS John Bean .Assistant Director of Primary & Community Care – Business Planning Tel: 01652 601147 David Fullard – Director of Corporate Affairs Tel: 01652 601182 Pauline Ling – Corporate Affairs/Risk Manager Tel: 01652 601121 Dr Brian Crompton – Director of Clinical Governance Tel: 01652 601238 Kathryn Helley – Assistant Director of Clinical Governance Tel: 01652 601154 Karen Fanthorpe – Assistant Director of Primary & Community Care – Clinical Services Tel: 01652 601112 Karen Rhodes .Health & Safety Officer Tel: 01302 796000 Geoff Day .Director of Primary & Community Care Tel: 01652 601145 Sue May – Clinical Development Coordinator Tel: 01652 601232 Brian Sellars – Director of Mental Health Services Tel: 01724 874919 Graeme Fagan .Head of Service Tel: 01724 874919 reviewed AIM May 200* 23 .
1 Insignificant Insignificant cost increase / schedule slippage. Use Table 1 to determine the Consequence score(s) C. on staff morale.APPENDIX C RISK QUANTIFICATION AND ACCEPTABILITY A simple approach to quantifying risk is to define qualitative measures of consequence/impact and likelihood. Non-compliance with core standards Loss > 0. Zero Rating. reviewed AIM May 200* 24 . Ongoing unsafe staffing level Loss > 0. STEP 2 use Table 2 (see over) to determine the likelihood scores for those adverse outcomes. Adverse Publicity / Reputation STEP 2 continued. which can be used as the basis of identifying acceptable and unacceptable risk. Table 1 – Consequence/impact Score (C) Descriptor Objectives / Projects. This allows construction of a risk matrix. Multiple justified complaints Multiple claims or single major claim Service / Business Interruption Loss / interruption > 1 hour Loss / interruption > 8 hours Loss / interruption > 1 day Loss / interruption > 1 week Permanent loss of service or facility Uncertain delivery of key objective / service due to lack of staff. Doesn't meet secondary objectives > 25% over budget / schedule slippage. Minor reduction in quality / scope 5 -10% over budget / schedule slippage. for the potential adverse outcome(s) relevant to the risk being evaluated. Challenging recommendations . Minor error due to poor training.1% of budget Inspection / Audit Minor recommendations Minor noncompliance with standards Recommendation s given. Critical error due to insufficient training Staffing and Competence Short term low staffing level temporarily reduces service quality (< 1 day) Ongoing low staffing level reduces service quality Financial Small loss Loss > 0. Low rating. or long term incapacity / disability (loss of limb) Death or major permanent incapacity Injury Minor injury not requiring first aid Minor injury or illness. Minor long term. Major non-compliance with core standards Loss > 1% of budget Prosecution. 10 . STEP 1 define the Risk(s) explicitly in terms of the adverse consequence(s) that might arise from the risk. Loss of key staff. Noncompliance with standards Late delivery of key objective / service due to lack of staff.25% over budget / schedule slippage. National Media < Rumours Days. Doesn't meet primary objectives RIDDOR / Agency reportable Major injuries. Reduction in scope or quality.5% of budget Enforcement Action. Critical report. Justified complaint involving lack of appropriate care Claim above excess level. MP Concern effect on staff Significant effect 3 Days (Questions in House) morale. Barely noticeable reduction in scope or quality 2 Minor 3 Moderate 4 Major 5 Catastrophic < 5% over budget / schedule slippage. Serious error due to poor training Non delivery of key objective / service due to lack of staff. Severely critical report Local Media Local Media National Media > 3 short term. first aid treatment needed Patient Experience Unsatisfactory patient experience not directly related to patient care Unsatisfactory patient experience readily resolvable Mismanagement of patient care Serious mismanagement of patient care Totally unsatisfactory patient outcome or experience Complaints / Claims Locally resolved complaint Justified complaint peripheral to clinical care Below excess claim.25% of budget Reduced rating.
and the likelihood score (L) from table 2 use the matrix below to determine the risk rated score (R) This should be a score of between 1 and 25. such as the lifetime of the project or the patient care episode. using table 2. If it is not possible to determine a numerical probability then use the probability descriptions to determine the most appropriate score. if (C) = 3 and (L) = 2 then (R) = 6 Risk Matrix Likelihood 1 2 3 4 5 R (Risk) = C (Consequence/impact) x L (Likelihood) 1 1 2 3 4 5 2 2 4 6 8 10 Consequence/Impact 3 3 6 9 12 15 4 4 8 12 16 20 5 5 10 15 20 25 STEP 4 Identify the level of the risk from the table below to see how the risk is to be managed. If this is not possible then assign a probability to the adverse outcome occurring within a given time frame.If possible. Risk rated score 1–3 4-7 Level of Risk Level at which risk is managed. Managed and monitored at Corporate level Reports to RMC/PECand Board with proposed treatment plans Managed and monitored at Corporate Level Reports to RMC/PEC and Board with proposed treatment plans 8-14 Significant Risk Require action and review 15-25 High/Principal Risk Unacceptable level of risk. recorded and kept under review. recorded and monitored Low An acceptable level of risk which remains subject to review and action Moderate Risk An acceptable level of risk which remains subject to review and action Managed and monitored at Directorate level in accordance with para 7 of Protocol for the implementation of local risk registers (Appendix F*) Managed and monitored at Directorate level in accordance with para 7 of Protocol for the implementation of local risk registers (Appendix F*). score the likelihood by assigning a predicted frequency of the adverse outcome occurring. Reports to RMC and Professional Executive Committee. Table 2 Likelihood Descriptor Frequency Probability 1 Rare 2 Unlikely 3 Possible 4 Likely 5 Almost Certain Not expected to Expected to occur Expected to occur Expected to occur Expected to occur occur for years at least annually at least monthly at least weekly at least daily < 1% 1 – 5% 6 – 20% 21 – 50% > 50% Will only occur in Reasonable More likely to exceptional Unlikely to occur chance of Likely to occur occur than not circumstances occurring STEP 3 Having identified the consequence/impact score (C) from Table 1 . Requires urgent/immediate review and action *Refers to Appendix F of the <COMPANY>’s Risk Management Strategy & Policy reviewed AIM May 200* 25 . For example.
equipment failure.APPENDIX D <YOUR COMPANY NAME> INVESTIGATING AN ACCIDENT/INCIDENT ROOT CAUSE ANALYSIS (RCA) ESTABLISH THE FACTS 1 ( ( ( Items to be considered ( ( ( Obtain copies of procedures/protocols Obtain statements of fact (signed and dated) Take photographs. maintenance. etc) Retain damaged/broken parts Copies of any routine Workplace Inspections ANALYSE THE FACTS 2 WHAT CAUSED THE ACCIDENT? eg Human error. measurements Obtain records sheets (training. ESTABLISH CAUSES 3 IMMEDIATE eg: i) ii) iii) Uneven path Worn equipment Incorrect procedure UNDERLYING (ROOT) eg: a) Lack of inspections and timely repairs b) Lack of routine maintenance c) Lack of training DECIDE ON APPROPRIATE ACTION TO PREVENT REOCCURRENCE 4 IMPLEMENT ACTION 5 SHORT TERM LONG TERM CHECK ACTION 6 Is it effective? Does it create any additional hazards or problems? Are better solutions now evident? . inappropriate protocol. lack of training.
The level of remedial action required will be linked to the <COMPANY>’s risk acceptability criteria (appendix F refers) The types of action which may be required could include some or all of the following: making the area safe wearing protective clothing removal of similar pieces of equipment. occupational health service. Out of Hours the Duty Director on-call can be contacted via switchboard at Scunthorpe General Hospital. Health and safety officer. Notify manager if not already on duty iii Manager to assess seriousness of incident: (The seriousness of the incident should be determined in accordance with the <COMPANY>’s adopted risk quantification and acceptability criteria). All adverse incidents should immediately be reported to the relevant <COMPANY> Senior Manager/Head of Department or a designated deputy. Human Resources. incorporating the serious untoward incident policy). Other persons whose advice may be appropriate in determining/enacting remedial action eg.APPENDIX E RESPONSE BY PERSON IN CHARGE/MANAGER/SENIOR CLINICIAN AT THE TIME OF THE INCIDENT i Ensure safety of situation ii. Security Management Director. For further information please see the policy and procedure for managing and reporting adverse incidents. Reviewing risk assessments or undertaking fresh risk assessment Making changes to clinical procedures referring staff to occupational health service taking witness statements vi. incorporating the serious untoward incident policy. although the Manager may use discretion on the timing of reporting to the Senior Manager/Director if the incident is contained and/or is not believed to be a “serious untoward incident”. v Remedial action. . vii. which should be implemented immediately. Iv Need for further investigation (guidance on root cause analysis investigations is also given in appendix E of the policy and procedure for managing and reporting adverse incidents. Ensure that relevant documentation is completed eg IR1 (Appendix Aii) Manager/person in charge/senior clinician or the person involved in the incident to report immediately to their director/Head of Department/Director of Corporate Affairs if the incident is believed to be a serious untoward incident and/or remains uncontained.
Health and safety officer. which should be implemented immediately. Other persons whose advice may be appropriate in determining/enacting remedial action eg. Remedial action. Manager/person in charge/senior clinician or the person involved in the incident to report immediately to their director/Head of Department/Director of Corporate Affairs if the incident is believed to be a serious untoward incident and/or remains uncontained.APPENDIX E RESPONSE BY PERSON IN CHARGE/MANAGER/SENIOR CLINICIAN AT THE TIME OF THE INCIDENT i ii. All adverse incidents should immediately be reported to the relevant <COMPANY> Senior Manager/Head of Department or a designated deputy. Security Management Director. incorporating the serious untoward incident policy. occupational health service. For further information please see the policy and procedure for managing and reporting adverse incidents. iii Ensure safety of situation Notify manager if not already on duty Manager to assess seriousness of incident: (The seriousness of the incident should be determined in accordance with the <COMPANY>’s adopted risk quantification and acceptability criteria). Need for further investigation (guidance on root cause analysis investigations is also given in appendix E of the policy and procedure for managing and reporting adverse incidents. Human Resources. Out of Hours the Duty Director on-call can be contacted via switchboard at Scunthorpe General Hospital. Ensure that relevant documentation is completed eg IR1 (Appendix Aii) vii. . The level of remedial action required will be linked to the <COMPANY>’s risk acceptability criteria (appendix F refers) The types of action which may be required could include some or all of the following: • • • • • • Iv v making the area safe wearing protective clothing removal of similar pieces of equipment. Reviewing risk assessments or undertaking fresh risk assessment Making changes to clinical procedures referring staff to occupational health service taking witness statements • vi. incorporating the serious untoward incident policy). although the Manager may use discretion on the timing of reporting to the Senior Manager/Director if the incident is contained and/or is not believed to be a “serious untoward incident”.
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