Guidance on completing the new incident report form This guidance should be read in conjunction with the Incident

Reporting Policy Background: From 1 January 2005, the National Patient Safety Agency (NPSA) will be collecting anonymised data about patient safety incidents from Trusts nationally. This data will populate the National Reporting and Learning System (NRLS) and will be used to ensure optimum learning from incidents. Only patient Safety incidents will be reported to NPSA NRLS. The NPSA has devised a minimum dataset of information that has to be supplied about each patient safety incident. The NHS outer north east London Incident report form has been designed to ensure that we are collecting the required information. The form will still be used to report non-clinical incidents, accidents, hazards and near misses. What is an Incident? The term incident means any adverse affect that can directly or indirectly compromise accepted standards of care, this includes clinical and non-clinical incidents, accidents, accidental injuries, near misses, serious untoward incidents, unusual and dangerous occurrences, damage to Trust property, plant or equipment, fires, medication incidents, security incidents and incidents involving medical devices and other equipment. (See A List of incidents to be reported.) What is a Patient Safety Incident? It is any unintended or unexpected incident that could have or did lead to harm for one or more persons receiving NHS funded healthcare. A No Harm Incident is one that caused no harm but was not prevented. A Near Miss is a patient safety incident that had the potential to cause harm but was prevented, resulting in no harm. Detailed guidance on completing the incident report form This guidance goes through each section of the Incident Form and gives examples to help you. N.B. Sections of the form marked with an M are mandatory and must be completed. If any mandatory fields are left blank, the form will be returned to you. 1. Where did the Incident take place: Mandatory field Site: e.g. Manford Way Health Centre Locality: e.g. North Central Directorate: e.g. Primary Care Service: e.g. Podiatry Dept/Ward/Other: e.g. Clinic Room Exact Location: e.g. Clinical Room 1 2. When did the Incident happen: Mandatory field Enter date and time of Incident, using 24hour clock 3. Person(s) involved/affected: If the person affected is a Patient, mandatory fields are sex, date of birth and patient ethnic code.
st

Select type of person i.e. member of staff or patient or visitor or contractor or agency/locum or other (specify). If the person involved is a member of staff, give their job title and grade. If the person involved is a patient, give their hospital number and name of their consultant. The details about the person must also be completed i.e. name, sex, date of birth, address & postcode, phone number (home/work). (The name will not be given to the NPSA.) 4. Description of incident: Mandatory field Give a full and clear account of the incident in the order that things happened. Ensure you state facts only, not opinions. Details of any injuries and treatment given should be entered in this section. If necessary, continue on a separate sheet and indicate on the bottom of page 2 of the Incident Report Form how many pages are attached. 5. Details of person reporting the incident: Mandatory fields are job title, grade and role in incident. Complete all details clearly; including your name and a contact number, we may need to contact you for further information. (Your name will not be given to the NPSA) Role in Incident: choose from the Role in Incident Codes Table on the Incident Report Form. 6. Details of staff involved/witnesses: Mandatory fields are job title, status and role in incident. Witnesses may be either staff or non-staff members. Statements may be needed and should be collected as close to the time of the incident as possible. Remember to include a contact number. Role in Incident: choose from the Role in Incident Codes Table on the Incident Report Form. 7. Details of Medical Device involved in the incident: Mandatory fields is type of device. If the incident involved a medical device or equipment, you must provide the details requested on the form and advise the Medical Engineering Manager from your locality. 8. Type of Incident: Mandatory field Select the incident code from the list supplied, which has been categorised to help you, and enter on to the Incident Report Form. See Appendix 1 List of Incidents to be reported. 9. Severity (degree of harm): Mandatory field All incidents clinical or non-clinical must be graded for severity. If you are uncertain about this, ask your line manager to help you. These are the categories: Category Impact to patients Impact to staff Impact Prevented: Impact Prevented: Had potential to cause harm, Had potential to cause harm, but the incident was but the incident was prevented prevented Impact Not Prevented: Incident occurred with no harm to patients Patients required extra observation or minor treatment Impact Not Prevented: Incident occurred with no harm to staff Staff did not need debriefing or injury resulted in 0-3 days if sick or unable to fulfil normal duties
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None

Low

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Moderate

Severe Death

Patients require moderate increase in treatment, did not lead to permanent harm Patients experienced permanent harm

Resulted in over 3 days of sick (see No. 11) Staff needed debriefing Resulted in major injury (as defined by RIDDOR see No. 11) Patient died as a direct result Staff died as a direct result of the incident of the incident

Injury code: Mandatory field If any degree of harm has occurred, the injury code must be selected from the list below and entered on to the incident report form. Details of any injuries and treatment given should be included in Section 4. A0100 A0200 A0300 A0400 A0500 A0600 A0700 A0800 A0900 Allergic/adverse reaction Awareness during GA Blood/fluid loss Collapse/loss of consciousness Nausea/vomiting/diarrhoea Infection Injury to skin (pressure ulcer/abrasion/sharps) Musculoskeletal injury Neurological effect A1000 A1100 A1200 ZA B C U Y Respiratory effect (choking/aspiration) Unexpected deterioration Unintentional puncture/laceration to organ/body part Other physical (specify) Psychological (specify) Social (specify) Unknown Not applicable

Describe any action which prevented the incident from reaching the patient or minimised the impact on the patient: Mandatory field The information is required as part of the earning process following incidents. 10. Patient safety incidents involving a child: Mandatory fields If the incident involves a child, this section must be completed. 11. RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences regulations) RIDDOR reportable incidents include: deaths, major injuries, accidents resulting in injury over 3 days, diseases, dangerous occurrences and gas incidents. Furthermore Reportable major injuries include: Fracture other than to fingers, thumbs or toes; Amputation; Dislocation of the shoulder, hip, knee or spine; Loss of sight (temporary or permanent); Chemical or hot metal burn to the eye or any penetrating injury to the eye; Injury resulting from an electric shock or electrical burn leading to unconsciousness or requiring resuscitation or admittance to hospital for more than 24hours; Any other injury: leading to hypothermia, heat-induced illness or unconsciousness; or requiring resuscitation or admittance to hospital for more than 24hours; Unconsciousness caused by asphyxia or exposure to harmful substance or biological agent; Acute illness requiring medical treatment, or loss of consciousness arising from absorption of any substance by inhalation, ingestion or through the skin; Acute illness requiring medical treatment where there is reason to believe that this resulted from exposure to a biological agent or its toxins or infected material.
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Over-three-day injury If there is an accident connected with work (including an act of physical violence) and your employee, or a self-employed person working on your premises, suffers and over-three-day injury you must report it to the enforcing authority within ten days. An over-3-day injury is one which is not major but results in the injured person being away from work or unable to do their full range of their normal duties for more than three days. 12. Details of medication involved in the Incident: Mandatory fields are stage and code If the Incident involved medication, this section must be completed. You should print the name of the drug, the form, the route (see table below), dose/strength and say whether it is part of a trial. You must indicate at what stage of the medication process the incident occurred (see choices on the Incident Report Form). The type of medication incident must also be selected from the list on the Incident Report Form. If the type of incident does not match one of these choices, please specify what type you think it is. You may need to discuss this with your manager. Route of medication Per ear Inhalation Epidural Intrathecal Intramuscular Intravenous

Nasal Optical Oral

Rectal Subcutaneous Sublingual

Topical Per vagina Intravesicular

Other Unknown Not applicable

13. What do you consider to be the underlying causes which, if rectified, may prevent another Incident? This information will be most relevant for Incidents graded as major critical or death. It will involve some investigation and/or root cause analysis into the underlying, less apparent cause of the Incident. For example, service delivery problems could include failure to undertake an environmental risk assessment or failure to ensure all new phones have emergency numbers on them. Care delivery problems could include failure to monitor/observe/act, or not seeking help when necessary. 14. Risk assessments Each incident should be assessed for its potential to occur again and the possible consequences. Managers should choose most appropriate fields for the incident. You are looking to identify the possible consequences should the same incident happen again. Take the severity in section 9 and use the tables below to identify the risk outcome. Likelihood Category Very Low Low Medium High Very High Percentage of likely reoccurrence 0-5 % 6-20 % 21-50 % 51-80 % 81-100 % Text description Extremely unlikely or virtually impossible Low, but not impossible Fairly likely to occur More likely to occur than not Almost certainly will occur

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Impact v Likelihood outcome Likelihood Very Low Low Medium High Very Low Severity None Low Low Low Moderate Moderate

Low Low Moderate Moderate High High

Moderate Low Moderate High High Extreme

Severe Moderate High High Extreme Extreme

Death Moderate High Extreme Extreme Extreme

15. Managers / team actions Please summarise immediate actions taken and future planned actions/changes to systems/processes that may be needed to prevent reoccurrence. You may continue on a separate sheet if necessary. A copy of the Incident report form may be offered to the person affected by the incident, or to their relative or carer, where appropriate. N.B. Please ensure that outcomes and learning from Incidents are disseminated back to teams and individual staff.

For further help/advice/clarification contact the Clinical Quality &Safety team on 020 8822 3012 Fax 020 8926 5107 or email nina.saumtally@onel.nhs.uk

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Appendix 1 list of incidents to be reported Clinical/patient safety incidents Code Description G01 Service: Reduction/closure/Staffing G02 Slip/Trip/Fall G03 Omission to act on clinical results/information G04 Absent: notes/records/tests etc G05 Communication failure G06 Consent issues G07 Verbal abuse/violence G08 Breach of confidentiality G09 Medication incident G10 Significant exposure to blood or bodily fluids G11 Equipment issues G12 Unexpected death (caused by the incident) G13 Injury caused by incident G14 Avoidable admission/unexpected readmission G15 Suicide/suicide attempt G16 Infection Control Issues G17 Pressure ulcer (development or management) G18 Handling issues G19 Porter / Domestic G20 Injury from sharps G21 Inappropriate contact with (hazardous substance etc) G22 Over exposure to (hazardous substances etc) G23 Research related incident G24 Child Protection incident G25 Hospital acquired bacteraemia MRSA G26 Vulnerable adult incident G27 Missing Patient G28 Inappropriate care G29 Unacceptable standard of care Health & safety incidents (involving staff) HS01 Incident only HS03 Needlestick/sharps injury (infection control) HS04 Cuts/grazes (non infection control) HS05 Slip/Trip/Fall HS06 Back/Neck Injury/Pain HS07 Falling from Height HS08 Bangs/Bumps/Accidental Collision HS09 Caught in/ Struck by HS10 Allergic Reaction HS11 Over Exposure to Biological Agents HS12 Over Exposure to Chemical Agents HS13 Upper Limb Injury HS14 Lower Limb Injury HS15 Explosion/fire HS16 Burns/Scalds HS17 Equipment Failure HS18 Property Damage HS19 Road Traffic Accident Involving Staff HS20 Violence Against/Involving Staff HS21 Loss of Property/Theft
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For further help/advice/clarification contact the Clinical Quality &Safety team on 020 8822 3012 Fax 020 8926 5107 or email nina.saumtally@onel.nhs.uk

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