Incident Reporting: Keeping you and the patient safe

Pauline CummingPauline Cumming

Risk ManagerRisk Manager

NHS FifeNHS Fife

Doctors’ Corporate InductionDoctors’ Corporate Induction

1 February 20121 February 2012

Is Safety an Issue in the NHS?

Patient accidents (falls)- Patient accidents (falls)- 28%28%

Treatment & Procedures -Treatment & Procedures -11%11%

Medication incidents -11%Medication incidents -11%

Other including admission Other including admission transfer , discharge -8% transfer , discharge -8%

(National Patient Safety Agency (NPSA)

September 2011)

Disruptive / Aggressive Behaviour Disruptive / Aggressive Behaviour (22% Mental Health Setting) (22% Mental Health Setting)

Patient Accidents (48% Patient Accidents (48% Community Setting )Community Setting )

Medication (24% General Practice) Medication (24% General Practice) ((National Patient Safety Agency , (NPSA),2010)

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

Everyone’s Everyone’s businessbusiness

What to report

Incident:Incident: An event or circumstance arising An event or circumstance arising during NHS service provision that could during NHS service provision that could have or did lead to unexpected harm, loss have or did lead to unexpected harm, loss or damage or damage

Near-miss:Near-miss: N No harm, loss or damage was caused but could have resulted in harm, loss or damage in other circumstances

Any member of staff can reportAny member of staff can report

Report as soon as possible after the event - report Report as soon as possible after the event - report Major / Extreme incidents immediately e.g. Major / Extreme incidents immediately e.g.

Unexpected deaths Unexpected deaths Incidents that resulted in a permanent injury, loss of Incidents that resulted in a permanent injury, loss of

function or loss of a body partfunction or loss of a body part Unplanned surgical intervention / transfer to ITUUnplanned surgical intervention / transfer to ITU

If more than one person is affected / involved, a If more than one person is affected / involved, a separate form must be completed for each individual separate form must be completed for each individual

Incident Reporting: Who & when?

How to report an incident

Two methods in use in NHS Fife:Two methods in use in NHS Fife:– Paper Form Paper Form – ElectronicElectronic

The electronic system -The electronic system -DatixWebDatixWeb -is -is gradually being rolled out across the gradually being rolled out across the organisation, replacing the paper formorganisation, replacing the paper form

How to report an Incident

To find out which method to use To find out which method to use and how to do so:and how to do so:– Ask the Charge NurseAsk the Charge Nurse in the wards/ in the wards/

areas in which you are working areas in which you are working To obtain further help and To obtain further help and

guidance:guidance:– Check the NHS Fife intranet under Check the NHS Fife intranet under

Risk Management – SubjectRisk Management – Subject

This is the paper form

This is the electronic form

What regularly gets missed off reports

Sub CategorySub Category Severity of harmSeverity of harm GradingGrading Drug names Drug names Manager reviewManager review Equipment detailsEquipment details Notifications - otherNotifications - other

Please try and include as much information as

possible…

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 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 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 timepenetrated 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 Patient with Parkinson's disease -dosage and timing of medication altered without consulting the Parkinson's Specialist Nurse. Doses & frequency of cocareldopa consulting the Parkinson's Specialist Nurse. Doses & frequency of cocareldopa documented on GP letter not transferred onto drug kardex on admission hence 10 days documented on GP letter not transferred onto drug kardex on admission hence 10 days under-medicated.under-medicated.

Incident Examples….

In conclusion…In conclusion…

““Identifying incidents and ensuring Identifying incidents and ensuring they are reported and analysed is at they are reported and analysed is at the heart of reducing risk in the heart of reducing risk in healthcare”healthcare”

Chief Executive, NPSA Chief Executive, NPSA

Contact:Contact:

Pauline Cumming, Risk ManagerPauline Cumming, Risk Manager

paulinecumming@nhs.netpaulinecumming@nhs.net

Ext 56279Ext 56279

Anne Mackinnon , Risk Management Anne Mackinnon , Risk Management Coordinator Coordinator

amackinnon@nhs.netamackinnon@nhs.net

Ext 35120Ext 35120

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!