Transcript How to report an Incident

Incident Reporting:
Keeping you and the patient safe
Doctors’ Corporate Induction
1 February 2012
Pauline Cumming
Risk Manager
NHS Fife
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
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Patient accidents (falls)28%
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Treatment & Procedures 11%
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Medication incidents -11%
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Other including admission
transfer , discharge -8%
(National Patient Safety Agency (NPSA)
September 2011)
Everyone’s business
Other Areas
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Disruptive / Aggressive Behaviour
(22% Mental Health Setting)
Patient Accidents (48% Community
Setting )
Medication (24% General Practice)
(National Patient Safety Agency , (NPSA),2010)
What to report
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Incident: An event or circumstance arising
during NHS service provision that could
have or did lead to unexpected harm, loss
or damage
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Near-miss: No harm, loss or damage was
caused but could have resulted in harm,
loss or damage in other circumstances
Incident Reporting: Who & when?
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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
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If more than one person is affected / involved, a
separate form must be completed for each individual
How to report an incident

Two methods in use in NHS Fife:
– Paper Form
– Electronic
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The electronic system -DatixWeb -is
gradually being rolled out across the
organisation, replacing the paper form
How to report an Incident
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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
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To obtain further help and guidance:
– Check the NHS Fife intranet under Risk
Management – Subject
This is the paper form
This is the electronic form
What regularly gets missed off reports
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Sub Category
Severity of harm
Grading
Drug names
Manager review
Equipment details
Notifications - other
Please try and include as
much information as
possible…
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.
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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.
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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 .
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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.
In conclusion…
“Identifying incidents and ensuring
they are reported and analysed is at
the heart of reducing risk in
healthcare”
Chief Executive, NPSA
Contact:
Pauline Cumming, Risk Manager
[email protected]
Ext 56279
Anne Mackinnon , Risk Management Coordinator
[email protected]
Ext 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!