Why do we have this policy?
It is the policy of ESHYFT to report and investigate all patient safety incidents in order to promote a culture of safety and to create learning opportunities for quality improvement. This document provides the steps to be followed when any patient safety incident occurs at any ESHYFT contracted facility with an ESHYFT staff member.
This policy defines the procedures and actions to be taken by the Clinical Director in response to an incident. The overriding emphasis is to identify why mistakes have occurred, to learn from the process, and not to attribute blame and punish. This does not absolve staff from professional accountability, but all the facts of an incident must be reviewed.
Research shows that it is rarely due to one person when a mistake occurs, but usually a combination of events, requiring consideration of all contributory factors and a thorough investigation before deciding any action required. Balanced in this approach is the need to counsel and support staff and facilities through any incident, potential or actual, and ensure appropriate action is taken to reduce the risk of the event occurring again.
Incident data are essential sources of knowledge and on-the-job training material. Incident investigation is a rich source of information that will help new staff understand why ESHYFT has a specific process that may differ from their previous workplaces. Similarly, having a robust incident management system helps implement a good continuous learning program for the staff that helps them learn the most important details they need to be efficient in their day-to-day work.
The ESHYFT Clinical Director is responsible for gathering information pertaining to any patient safety incident.
What does this policy identify?
As such, this policy identifies:
The process for reporting all internal and external reportable incidents/near misses involving staff, patients, and others.
The types of incidents to be reported.
The importance of intervening quickly to reduce the effects of an incident that affects a patient, visitor, or member of staff.
How the information from reported incidents is used to improve patient care and the learning shared across all levels of the organization.
The process to ensure lessons learned from an incident will be applied generally wherever appropriate so that recurrence is reduced and subsequent risk reduced.
The systems in place to provide feedback to each staff member.
Documenting any required actions regardless of whether the incident is clinical or non-clinical.
Identifying risks at the local level, including risks from reported incidents, and reviewing and reporting on actions that contribute to the risks.
The process for effective reporting to statutory and relevant external agencies.
What is an incident?
An incident is defined as any event or circumstance that could have the potential to/or did lead to unintended or unexpected, harm, loss, or damage. These may be clinical or non-clinical events and can affect staff, patients, or the facility.
Who is responsible?
All staff who are employed at ESHYFT have a responsibility to report incidents, whether they are clinical or non-clinical, regardless of whether other people could also have seen them.
Reporting
For incidents involving patients, inform the DON at the facility and the ESHYFT Clinical Director. If necessary, contact the relevant medical personnel at the facility to assess the patient’s clinical condition and the likelihood of any detrimental effect on their care, or immediate action that may be required.
Support staff members and discuss the incident with them. The discussion's purpose is to support the individual and identify exactly ‘what’ happened and ‘why’. Consideration should be made of the contributory factors in relation to incidents, for example, training needs, lack of supervision, or interruptions. Consideration also needs to be taken into how likely the incident is to recur. This will form the basis of what action (if any) is needed.
In the rare event that the incident has resulted in a criminal investigation, the staff member involved will usually be suspended pending investigation.
Types of incidents:
Not completing assignments; charting, care, feeding, ignoring call bells
Arriving late, leaving early
Sleeping on the job
Rude, yelling, unprofessional, confrontational behavior
Being on their phone during patient care time
Job abandonment (as defined by the state where they are employed)
Refusing an assignment
Medication errors: wrong meds, wrong resident, wrong dosage, not giving the meds.
2-person assist performed alone (patient safety is compromised)
Missing during the shift, hiding out in rooms
Posting negative information on social media
Abuse investigations (verbal, physical, financial)
Neglect
Suspected to be under the influence
Missing narcotics
Investigation of incidents will not be determined with any prejudice to the following:
Age
Disability (including learning disability)
Gender reassignment or expression
Marriage or civil partnership
Pregnancy and maternity
Race
Religion or belief
Sex
Sexual orientation
Clinical Director's Response Procedure
Immediate response once a patient safety incident has been reported by the Clinical Director.
Address immediate health/safety/operational issues as applicable to a patient safety event. Complete a debrief with involved individuals.
Perform an initial review of the incident within a reasonable time frame.
Record any review/follow-up that occurred.
Enter a short description of the outcome action steps taken since the event.
Analyze staff member's incident data for trends and opportunities for patient safety improvement.
Assume responsibility for instituting appropriate policy and procedural changes to address quality of care issues.
Incident Reporting
Incident reporting is a powerful source of information. When used effectively, it provides a factual description of an adverse event or near miss that supports learning, safety and improved care quality.
Incident reporting systems are used to gather information using a structured format. This facilitates analysis of this data using metrics such as event type, frequency, severity, location, day, date, and time of occurrence in the workplace.
The investigation aims to understand what happened, identify how future incidents may be prevented, and ensure that the conclusions in the final report are fair, evidenced, and reasoned.