Incident Reporting and Investigation Training for Managers and Incident Investigators Philip Condie Health & Safety Manager Rev. March 2009
Programme • Welcome and introductions • Definitions • Introduction to the Trust Incident Policy • Guided tour of IRIS Form IR1 • Incident grading • Investigation techniques • Common lessons learnt from incident investigations • Incident investigation - worked example
Objectives By the end of the session, you will be able to: • describe and instruct staff in the procedure for reporting incidents • check incident reports for completeness and quality of information • review and grade incident reports according to likelihood & consequence • understand the principles of investigation • carry out an investigation of a work-related incident • develop action plans to reduce or eliminate recurrence
The legal bit • The Social Security (Claims and Benefits) Regulations 1979 require employers to record any accidents involving employees. • The Reporting of Injuries, Diseases & Dangerous Occurrences Regulations 1995 require certain incidents to be reported to the HSE. • The Trust is required to comply with various risk management standards that require incidents to be reported, investigated and lessons learnt • Trust policy requires “.. all staff…to systematically, effectively and efficiently report and record all incidents, accidents and near misses ..” Furthermore…… • The Management of Health & Safety at Work Regulations 1999 requires employers to identify, assess and control hazards at work. • Incident reports are one way of identifying these hazards.
Definitions • Adverse incident - where injury, harm , damage or loss does occur (includes accidents) • Adverse event – where it doesn’t occur through luck or skilful management (includes near misses) • Serious Untoward Incident (SUI) – “something out of the ordinary or unexpected which is likely to be damaging to the NHS and attract media, ministerial or public attention.”
Trust policy • Roles and responsibilities • Timescales • Patient/ relative/ contractor involvement • Incident investigation incl. grading • Management of action plans • Incident and causal factor analysis • App 1 - Incident reporting levels • App 2 - Classification of incidents/ accidents
What is the purpose of incident reporting and investigation? Reporting and investigating incidents is one of two ways of managing events that can cause injury, ill health or other harm BEFORE harm occurs AFTER harm has occurred HARMFUL EVENT RISK ASSESSMENT INCIDENT INVESTIGATION PREVENTION is better than CURE?
Sharing information • Internal – you, your team, your manager, the Trust • External - your patients and their relatives/ carers, outside agencies e.g. • Health & Safety Executive • National Patient Safety Agency • Medicines and Healthcare products Regulatory Agency • Counter Fraud and Security Management Service • Strategic Health Authority • Department of Health • Police • Other service providers e.g. other Trusts, Social Services, GP, contractors (e.g. NHSP)
Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 • Some work-related incidents have to be reported to the Health & Safety Executive. • These primarily involve staff but can include service users and visitors • For injuries, these incidents must be reported to the HSE within 10 days of occurrence • For ill-health, to be reported within 10 days from the date of diagnosis • RIDDOR reports completed on-line by relevant manager at http://www.kmpt.nhs.uk/NetsiteCMS/pageid/364/index.html See HS Advice Note 6
RIDDOR reportable incidents 2008 (2006) TOTAL: 49 (62)
Incident reporting Incident reported as SUI if relevant Manager reports to HSE etc if required
IRIS form • SUI now part of the overall incident reporting process • Medication incidents to be reported on IRIS • Incident reporter determines “Incident level” between 1 – 5 • New Picklist 2A introduced • “Mandatory” fields introduced • Reporter contact details • Re-grading following investigation • Inclusion of sensitive data on IRIS forms • May relate to staff, patient or visitor etc • Must maintain confidentiality • Individuals should be informed that the information has been recorded and the reason it has been recorded (where this is inappropriate it must be recorded on the IRIS form) • Advice available from Information Rights Department
Guided tour FRONT COVER: Important instructions, step-by-step guide, contact details INSIDE FRONT COVER: Picklists 1 – 4 and 7 - 12 INCIDENT REPORT, IR1 Blue (double-sided), Pink and White copies WRITING SHIELD: Clinical Incident picklists 5 and 6
Group Exercise 1: Incident classification Classify the following incidents using definitions in Section 1 of the IRIS form: • 1. Agency staff fail to turn up for a shift – patient care may have been compromised • 2. Patient spills hot soup into lap • 3. Staff mislay their ID badge • 4. Staff hear patient call out and find them lying on the lounge floor • 5. Staff receives a needlestick injury • 6. The recorded dose on a medication bottle label does not match the prescription • 7. Confused patient pinches staff during bathing • 8. Staff develops eczema from wearing latex gloves • 9. Medical records are faxed to a garden centre instead of the CMHT • 10. Relative argues and swears at nurse over care of patient • 11. Patients blood sample goes missing in transit requiring re-bleeding • 12. Staff on a conference, slip and fall down London Underground escalator • 13. Patient suffers angina attack whilst waiting to attend phlebotomy appointment
Completing the IRIS form • Incident reporter completes all relevant sections • In Section 1, “incident level” determined • Incident reporter signs report and passes it to their manager or trained incident investigator to complete • Manager or Incident Investigator reviews report and grades incident • Grading confirms/ amends “incident level” and determines further actions • Incident Investigator feeds back grading and further actions to be taken.
Risk Screening Matrix • Definitions of Consequence and Likelihood can be found in the Adverse Incident Policy • Refer to 5 x 5 matrix to determine “grading” of incident • Multiple Incident investigation – aggregation of a number of “low consequence/ likelihood” incidents
Likelihood Severity/ Consequence Insignificant (Level 1) Minor (Level 2) Moderate (Level 3) Major (Level 4) Catastrophic (Level 5) Rare Unlikely Possible Likely Almost Certain Incident grading
Group Exercise 2: Risk screening For each of the following, assess Consequence/ Level and Likelihood and determine the grade: • The recorded dose on a controlled medication bottle label does not match the prescription. This has occurred before. • Staff hear patient call out and find them lying on the lounge floor. Diagnosed with a fractured neck of femur. Has never occurred before. • Medical records are faxed to a garden centre instead of the CMHT. Has not occurred to this team but has occurred elsewhere in the Trust. • Confused patient pinches staff during bathing, causing reddening. Occurs frequently to same member of staff
IRIS Form processing Following completion of the Incident Report, IR1, the Incident Reporter informs the Incident Investigator. The Investigator: BLUE COPY Completes risk screening. Retain if further investigation is to be undertaken and complete reverse. If no investigation, send to: …………….. When investigation completed, send to: …………………….. PINK COPY Remove following risk screening and place in staff or patient file WHITE COPY Remove following risk screening and store in a secure place.
What investigations seek to find Investigations seek to find causes that can then be controlled and factors that can be fixed. 1. Underlying causes Those things that had a direct influence at the time of the incident, either causing it or contributing to it. 2. “Other” factors Not directly involved but found to be “wanting” 3. Root causes The primary reason or reasons why the incident occurred.
Group Exercise 3:Common underlying causes • Communication – between individuals, teams, service providers • Training • Policies/ procedures/ guidelines/ protocols • Risk assessment • Environmental factors, including buildings and facilities • Equipment • Information and instructions • Time • Staffing issues – numbers, competence, supervision • Conflicting priorities • Resources • Individual factors – attitude, health, well-being, stress
Guided tour of Incident Investigation report • Investigation Record what actually happened, how and why. Include any control measures that were in place at the time but did not work/ were not used. • Underlying causes From the notes, identify one or more causes/ factors that were present at the time, or otherwise influenced the outcome of the incident. Root Causes Only complete if incident is a SUI. Record brief summary of identified root causes. • Action plan For each underlying cause, identify one or more actions to reduce or eliminate recurrence • Completion Keep copy, feedback, include attachments
Group Exercise 4:Toolkit for investigation • Interview with all persons involved/ statements • Photographs • Drawing of scene including position of people, equipment • Measurements • Policies and procedures relevant to task/ area/ patient/ person • Training and attendance records • Reports, investigations and actions of previous incidents • Communications/ instructions • Safety signs/ notices in place at time • Equipment involved including any personal protective equipment • Equipment maintenance/ servicing records • Technical data for equipment, flooring, lighting, infection rates (see “Other specialists”) • Visit to actual location • Demonstration of what was happening at time of incident (without harm!) • Other specialists eg estates, infection control, moving and handling, PSTS, health and safety
Further investigation techniques Problem identification: • Brainstorming • Nominal Group Technique – brainstorming with voting • Change analysis – what we used to do; what we do now; spot the difference Problem exploration: • Fault Tree Analysis/ Event Tree Analysis • The 5 “why’s” • Fishbone/ Ishikawa diagrams (identifies contributory factors) • Cause and effect diagrams, incorporating time lines (NASA Challenger) • Run charts (incident trends chart) Problem resolution: • Refer to NPSA Incident decision tree
Action You are the injured persons manager • Complete the incident report • Grade the incident • Consider the facts brought out during the investigation and use these to write a brief description of what you believe really happened and why. • Identify underlying causes • Write up action plan to address causes
Review of objectives You will now be able to: • describe and instruct staff in the procedure for reporting incidents • check incident reports for completeness and quality of information • review and grade incident reports according to likelihood & consequence • understand the principles of investigation • carry out an investigation of a work-related incident • develop action plans to reduce or eliminate recurrence
Handouts • Presentation slides • Trust Incident Level descriptors • Definitions of likelihood and consequence • Partially completed IRIS form and book for practical session • RIDDOR reportable categories • RIDDOR reporting Advice Note 6 • NPSA Incident Decision Tree