Incident Reporting: Keeping you and the patient safe

1. Incident Reporting: Keeping you and the patient safe Doctors’ Corporate Induction 1 February 2012 Pauline Cumming Risk Manager NHS Fife

2. Is Safety an Issue in the NHS? Research shows that 1 in 10 patients in Scotland may experience an adverse event (such as contracting an infection) in hospital. Half of these adverse events are believed to be avoidable Acute Setting Other Areas • Patient accidents (falls)- 28% • Treatment & Procedures -11% • Medication incidents -11% • Other including admission transfer , discharge -8% (National Patient Safety Agency (NPSA) September 2011) • Disruptive / Aggressive Behaviour (22% Mental Health Setting) • Patient Accidents (48% Community Setting ) • Medication (24% General Practice) (National Patient Safety Agency , (NPSA),2010) Everyone’s business

3. What to report • Incident:An event or circumstance arising during NHS service provision that could have or did lead to unexpected harm, loss or damage • Near-miss: No harm, loss or damage was caused but could have resulted in harm, loss or damage in other circumstances

4. Incident Reporting: Who & when? • Any member of staff can report • Report as soon as possible after the event - report Major / Extreme incidents immediately e.g. • Unexpected deaths • Incidents that resulted in a permanent injury, loss of function or loss of a body part • Unplanned surgical intervention / transfer to ITU • If more than one person is affected / involved, a separate form must be completed for each individual

5. How to report an incident • Two methods in use in NHS Fife: • Paper Form • Electronic • The electronic system -DatixWeb -is gradually being rolled out across the organisation, replacing the paper form

6. How to report an Incident • To find out which method to use and how to do so: • Ask the Charge Nurse in the wards/ areas in which you are working • To obtain further help and guidance: • Check the NHS Fife intranet under Risk Management – Subject

7. This is the paper form

8. This is the electronic form

9. What regularly gets missed off reports • Sub Category • Severity of harm • Grading • Drug names • Manager review • Equipment details • Notifications - other Please try and include as much information as possible…

10. Incident Examples…. • Incorrect dose of chemotherapy prescribed for second cycle in a row for a patient on gemcitabine/ carboplatin. Cycle 1 day 1 dose incorrectly prescribed at 1672mg instead of 1862mg. This was corrected on Day 8 at 1862mg, but on cycle 2 the Dr prescribed 1672mg once again. When contacted by the pharmacist, Dr admitted that they had "copied the wrong day's dose from the previous cycle." Doses should be calculated every cycle, not copied from previous cycles.Pharmacist spoke to Dr and amended the prescription after clarifying what the correct dose should be. • Patient was at theatre. On admission the family stated that he had previously had a reaction to morphine leaving him confused. Despite having a red allergy band and the drug kardex detailing this allergy and the family's obvious concerns the patient was given intrathecal morphine 0.1mg. This has resulted in increased confusion and poor mobility leading to falls. • Patient was given morning insulin twice in error. First staff member gave patient insulin to self administer, signed kardex as self administered but not the insulin prescription sheet. 2nd staff member saw unsigned prescription sheet, did not check kardex as not there and allowed patient to self administer a second dose. Patient forgot about first dose so did not alert staff alert . • After failing to gain IV access on a patient, I accidentally sustained a penetrating sharps injury with the used blue venflon in the process of discarding it in the nearby sharps bin. It penetrated the terminal of my left thumb. I was wearing gloves at the time • Patient with Parkinson's disease -dosage and timing of medication altered without consulting the Parkinson's Specialist Nurse. Doses & frequency of cocareldopa documented on GP letter not transferred onto drug kardex on admission hence 10 days under-medicated.

11. In conclusion… “Identifying incidents and ensuring they are reported and analysed is at the heart of reducing risk in healthcare” Chief Executive, NPSA

13. Contact: Pauline Cumming, Risk Manager paulinecumming@nhs.net Ext 56279 Anne Mackinnon , Risk Management Coordinator amackinnon@nhs.net Ext 35120

14. Key principles of solution creation • Design tasks and processes that minimise dependency on short term memory, attention span & avoid fatigue • Simplify tasks, processes and so on • Standardise processes & equipment • Use tools and checklists wisely • Make it easier to do the right thing!