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Health & Safety Policy Arrangements – Adverse Events (Accidents & Incidents) Post Event Reporting
Health & Safety Policy Arrangements
HSA07 (Ref. Code)
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Health & Safety Policy Arrangements – Adverse Events (Accidents & Incidents) Post Event Reporting
Version Control table
(to be included)
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Health & Safety Policy Arrangements – Adverse Events (Accidents & Incidents) Post Event Reporting
1. Purpose
These corporate arrangements set specific standards for the reporting (post event) and investigation of accidents and incidents in order that the objectives of the corporate health, safety and environmental policy may be achieved.
All colleges and professional service units (PSU) are required to report and investigate accidents and incidents in accordance with these arrangements.
Swansea University has a duty to ensure that all hazards are controlled and that risk control measures are implemented to reduce risks to an acceptable level in order to prevent accidents and cases of ill health. When an adverse event occurs it is important to review whether control measures are adequate. It is possible to learn lessons from near misses that can in turn prevent costly accidents.
Swansea University is committed to recording and investigating adverse events to:
Comply with relevant legislation Ensure that as an organisation, we are operating within the law Identify deficiencies in risk control management and make improvements Prevent further similar adverse events Monitor statistics and identify trends
Certain incidents must be reported to the HSE within statutory time limits as a requirement of the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR).
All employees, students, contractors, visitors and others associated with the University are positively encouraged to report adverse events that arise out of the work of Swansea University. This includes work duties that may take place off campus e.g. meetings, visits or field trips.
Terms used within the arrangements:
Adverse event includes:
accident: an event that results in injury or ill health; incident:
- near miss: an event that, while not causing harm, has the potential to cause injury or ill health. (includes dangerous occurrences) or damage to the environment;
- undesired circumstance: a set of conditions or circumstances that have the potential to cause injury or ill health, e.g. untrained members of staff handling heavy loads or damage to the environment;
Dangerous occurrence: one of a number of specific, reportable adverse events, as defined in the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR). (Appendix 1 )
Hazard: the potential to cause harm, including ill health and injury; damage to property, plant, products or the environment or increased liabilities.
Immediate cause: the most obvious reason why an adverse event happens, e.g the guard is missing; the employee slips etc. There may be several immediate causes identified in any one adverse event.
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Health & Safety Policy Arrangements – Adverse Events (Accidents & Incidents) Post Event Reporting
Environmental damage to any of the following
o protected species or natural habitats, or a SSSI o surface water or groundwater o marine waters, which means damage to marine waters such that their environmental status is
significantly adversely affectedo land by means of contamination from substances, preparations, organisms or micro-organisms that
result in a significant risk to human health
The Environmental Damage Regulations apply to serious environmental damage to land, water and to species and habitats. The Regulations aim to prevent environmental damage to prevent, limit or remediate environmental damage. They apply to damage to protected species, natural habitats, sites of special scientific interest (SSSIs), water and land.
Likelihood that an adverse event will happen again:
certain: it will happen again and soon; likely: it will reoccur, but not as an everyday event; possible: it may occur from time to time; unlikely: it is not expected to happen again in the foreseeable future; rare: so unlikely that it is not expected to happen again.
Consequence:
Fatalwork-related death.
Dangerous occurrencecertain, specified ‘near miss’ events with the potential to cause harm.
Specified injury/ill healthincluding fractures (other than fingers or toes), amputations, loss of sight, a burn or penetrating injury to the eye, any injury or acute illness resulting in unconsciousness, requiring resuscitation or requiring admittance to hospital for more than 24 hours;
Over 7 day injurieswhere the person affected is unfit to carry out his or her normal work for more than 7 consecutive days;
Over 3 day injurieswhere the person affected is unfit to carry out his or her normal work for more than three consecutive days;
Injury to non-workerswork-related accidents involving members of the public who are not at work and are injured and taken to hospital for treatment to that injury;
Minor injuryall other injuries, where the injured person is unfit for his or her normal work for less than three days;
Damage onlydamage to property, equipment or the environment.
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Health & Safety Policy Arrangements – Adverse Events (Accidents & Incidents) Post Event Reporting
Significantsignificant adverse effect on reaching or maintaining the favourable conservation status of the protected species or natural habitat including following:
- damage or danger to the natural environment- pollution of water or land- illegal tree felling- fish in distress or dead fish- wildlife crime that has already been committed- destruction of bat roosts- blocked main watercourses, or other blockages that might
pose a risk of flooding- illegal dumping of hazardous waste or large amounts of
industrial waste- incidents involving odour and noise- burning of any waste type, including asbestos- damage to Sites of Special Scientific Interest- illegal waste sites and unlicensed waste carriers- sightings of invasive/non-native species- spillage of special, hazardous or restricted substances (e.g. oil,
detergent, paint)
Risk/Environmental Aspect: The level of risk is determined from a combination of the likelihood of a specific undesirable event occurring and the severity of the consequences (ie how often is it likely to happen, how many people could be affected and how bad would the likely injuries or ill health effects be)
Risk control measures: are the workplace precautions put in place to reduce the risk to a tolerable level.
Root cause: an initiating event or failing from which all other causes or failings spring. Root causes are generally management, planning or organisational failings.
Underlying cause: the less obvious ‘system’ or ’organisational’ reason for an adverse event happening, e.g pre-start-up machinery checks are not carried out; the hazard has not been adequately considered via a suitable and sufficient risk assessment etc.
Relevant person: any person outlined who is assigned responsibility in the reporting and investigation of adverse events
2. Legislation Requirements
2.1 Legislation
Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR) Management of Health & Safety at Work Regulations 1999 Social Security Administration Act 1992 The Environmental Damage Regulations 2009
2.2 Guidance
HSG245 – Investigating Accidents and Incidents
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Health & Safety Policy Arrangements – Adverse Events (Accidents & Incidents) Post Event Reporting
3. Roles & Responsibilities & Responsibilities
In addition to the roles and responsibilities set out in the Health and Safety Policy, the following tasks will be required to manage in accordance with these arrangements:
3.1 Head of College/ Director of Professional Service Unit (PSU)
It is the responsibility of the Head of College/ Director of PSU to ensure that all adverse events and dangerous occurrences involving staff, students, visitors and contractors in their dept. and/ or property for which they have responsibility, are reported, investigated and corrective/ preventative action is identified, assigned and completed.
In order to fulfil this responsibility Heads of College/ Directors of PSUs must:
Ensure that the requirements and procedures for reporting adverse events and dangerous occurrences are adequately communicated throughout the College/ PSU, to staff, students, contractors and visitors and that procedures are followed.
Ensure that appropriate staff receive suitable training and can demonstrate competency to carry out their role in adverse event and dangerous occurrence reporting, investigation and recording;
Liaise, where appropriate, with the Safety, Health & Environment team and management within other Colleges/ PSUs in relation to adverse event investigations.
Review adverse events reports for the College/ PSU, indicate the status of recommendations and ensure their effectiveness.
Ensure, so far as reasonably practicable, that adequate financial provision is made available to complete actions resulting from adverse event investigations.
Ensure that records of adverse events together with the progress of recommended corrective/ preventative action are maintained and stored appropriately.
3.2 Managers/ Iine manager roles
Managers and supervisors must:
Ensure they are aware of the requirements and procedures for the reporting of adverse events and dangerous occurrences at the University of Swansea.
Ensure that members of staff and students within their areas of responsibility are aware of the University’s requirements and procedures for reporting adverse events and dangerous occurrences.
Ensure that any adverse event or dangerous occurrence they are aware of is reported within 2 days, investigated and recorded in line with procedures using the online reporting form.
Cooperate with any adverse event or dangerous occurrence investigation. Ensure that corrective and preventative actions identified following an investigation are
implemented and reviewed to ensure their effectiveness. Familiarise themselves with RIDDOR reporting requirements and procedures to ensure the
Safety, Health and Environment team are informed as soon as possible.
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Health & Safety Policy Arrangements – Adverse Events (Accidents & Incidents) Post Event Reporting
Report all environmental adverse events to the Safety, Health and Environment team within the University, who will then contact Natural Resources Wales after assessing the severity of the event and resulting damage.
Report the outcomes of investigations to the Head of College/ Director of PSU and College/ PSU H&S Management Steering Group.
3.3 Health and Safety/ EMS Coordinator (College/ PSU)
The role of the Health and Safety/ EMS Co-ordinator is to facilitate and co-ordinate reporting, recording and investigation of adverse events by:
Informing the relevant members of staff of reporting and investigation requirements in line with procedures
Immediately notifying the Safety, Health and Environment team following the occurrence of a notifiable adverse event and ensuring the report is submitted within 2 days.
Depending on the level of severity, in line with the procedures, leading or assisting with investigations and providing technical input
Advising the Manager/ Supervisor who is participating in the investigation on requirements for the report and assisting in the preparation and circulation of the report
Attending the College/ PSU SHE Management Steering Group to report on adverse events and investigations.
Providing advice to the College/ PSU SHE Management Steering Group on any proposed changes that may arise from investigations.
3.4 Safety, Health & Environment team
The Safety, Health and Environment team ensure that requirements and procedures for the reporting of adverse events and dangerous occurrences are reviewed, updated and adequately communicated throughout the University to staff, students, contractors and the public.
The team are responsible for:
Reporting all notifiable incidents to the relevant statutory authorities and assist with any subsequent enquiries or investigations
Notifying the Deputy Director of Safety, Health and Environment and Director of Estates & Facilities Management of adverse events and dangerous occurrences in line with procedures
Notifying Occupational Health and HR of injuries sustained by employees in line with procedures
Notifying the University Insurance Officer - Finance dept in relation to adverse events and dangerous occurrences as appropriate
The review and endorsement of the level of investigation required by Colleges/ PSUs Taking the lead in investigating or advising on investigations, in line with procedures, any
adverse events occurring on the University premises or arising out of the work of the University
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Health & Safety Policy Arrangements – Adverse Events (Accidents & Incidents) Post Event Reporting
Liaising, where appropriate with line managers and supervisors in Colleges / PSUs in relation to investigations.
Monitoring the adequacy of investigations undertaken and the appropriateness and effectiveness of the corrective/ preventative actions recommended
Reviewing the implementation and effectiveness of recommended corrective/ preventative actions from previous adverse events
Disseminating relevant information arising from adverse event investigations to Colleges/ PSUs including Occupational Health, HR and Finance, as appropriate
Providing periodical statistic returns to College/ PSU SHE Steering Management Steering Groups and SHE Committee
Providing advice on corrective/ preventative action recommended and/ or make further recommendations as necessary
Reviewing the level of investigation required by Colleges/ PSUs and Ensuring records are kept of all adverse events and dangerous occurrences reported
through the University’s reporting procedure
3.5 Security
Security are responsible for receiving emergency ‘333’ calls. Where the emergency call relates to an adverse event (level 1 or 2) including a fatality, major environmental leak or emission or RIDDOR specified injury or dangerous occurrence reportable to statutory authorities, the Incident Management Plan will be initiated.
Adverse events that take place outside of normal working hours and are attended to by security must be reported in line with procedures. Reports must be made within 2 days of the adverse event to SHE and the relevant College/ PSU H&S and/ or EMS Coordinator via the online reporting form.
3.6 HR and Occupational Health
To maintain effective communication with the Safety, Health and Environment team in relation to notifying:
Absence from work of any member of staff of 7 days or more following injury in the workplace or in the course of carrying out work duties
Cases of reportable occupational illness and illnesses that have been caused by workplace activities
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Health & Safety Policy Arrangements – Adverse Events (Accidents & Incidents) Post Event Reporting
3.7 Employees
All Swansea University employees shall:
Ensure they are aware of the requirement and procedures for reporting adverse events Ensure any adverse event they are aware of is reported through the appropriate
procedures Cooperate fully with any investigation
3.8 Contractors
Contractors undertaking work for Swansea University on university premises should make reports of adverse events through Swansea University procedures as well as their own. Contractors could include those brought in by Estates and Facilities Management, Student Union, retail outlets on campus, delivery drivers, contract cleaners etc.
3.9 Student Union
The student’s union shall:
Ensure they are aware of the requirement and procedures for reporting adverse events Ensure any adverse event they are aware of is reported through the appropriate
procedures Cooperate fully with any investigation
3.10 Students
Students shall:
Ensure they are aware of the requirement and procedures for reporting adverse events Ensure any adverse event is reported through the appropriate procedures Cooperate fully with any investigation
3.11 Visitors
If any visitor to the university is involved in an adverse event it should be reported by a member of Swansea University staff using the appropriate procedures.
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Health & Safety Policy Arrangements – Adverse Events (Accidents & Incidents) Post Event Reporting
4. General Arrangements & Working Practices
4.1 What should I report and in what timescales?
All adverse events must be reported post event and include:
4.1.1 Incidents or injuries to staff, students, contractors and visitors whilst in university owned or occupied buildings and grounds.
4.1.2 Incidents or injuries to staff, students, contractors and visitors sustained whilst engaged in University activities.
4.1.3 Incidents involving environmental damage to land, water, protected species, natural habitats, sites of special scientific interest (SSSIs), noise levels within local communities that exceed regulatory limits and that result from any activity undertaken by the university.
4.1.4 Ill-health that has been caused by, or made worse by work, as reported by a GP
Adverse events can be reported in two ways:
Quick report form: the quick report form is available on the SHE website and can be used to report hazards or concerns e.g.trip hazard. It can also be used to provide an initial quick report for any low level adverse events (level 3 and 4) outlined in section 4.2.2 before the full adverse report form is completed. Any hazards that present a risk to anyone should also be reported to the estates helpdesk for rectification.
Adverse report form: an electronic adverse report form is available on the SHE website and is also available in a word doc format if required. The preferred method for reporting is via the electronic report form. This form should be completed for all adverse events resulting in an injury or damage to the environment.
Timescales: All reports should be made to your line manager as soon as practicably possible following the event. An adverse event form must be completed using the adverse event e-form on the University website within 2 days of the adverse event occurring.
If the adverse event is likely to become RIDDOR reportable it should be reported within 2 days by the line manager. If full details of what happened during the adverse event are not available, the quick adverse event e-form can be completed until more details can be established. The important thing is that the adverse event is reported.
The adverse event should not be reported via the e-form on the website if it is ongoing and requires emergency assistance. If emergency assistance is required the emergency plans/ procedures relating to the event should be initiated and/ or call ‘333’ for Security involvement and to invoke the University Incident Management Plan.
Adverse event occurs
Take prompt emergency action e.g first aid.
Call 333 for assistance
Make the area safe
Preserve scene
People, equipment, witnesses
noted
Report to Relevant Person -
Post Event
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Health & Safety Policy Arrangements – Adverse Events (Accidents & Incidents) Post Event Reporting
4.2 What should I do following an adverse event
All Colleges/ PSUs must have written emergency procedures relevant to the hazards associated to the tasks and activities undertaken.
4.2.1 Emergency response
The initial immediate action to take will depend on the severity of the situation. Local emergency procedures should be initiated. The adverse event report levels correspond to the seriousness of the event. If the event is serious (level 1 or level 2) and the emergency number 333 has been called the Incident Management Plan will initiate and the emergency response and investigation will be coordinated by the Incident Management team.
4.2.2 Initial report
Preserve the scene (where appropriate) and report: (new quick report form and online report)
Location Names and contact details of witnesses People involved Time of adverse event Description of what happened Actions taken e.g. valves shut off, spill kit
used Damage
This information should be reported by the quickest practicable means.
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Health & Safety Policy Arrangements – Adverse Events (Accidents & Incidents) Post Event Reporting
Leaks or emission of fuel, oils, chemicals, biological agents
ADVERSE EVENT REPORT LEVELS
1 Major: Significant environmental damage which is long-term/ permanent damage to the environment e.g. release of dangerous substances into atmosphere or water bodies which has caused permanent damage to the habitat.
2 Minor: Environmental damage with reversible impacts which can be rectified with/ without interventions
Initiate emergency procedures.
Report to: Line Manager/ H&S/EMS Coordinator
Any other incident that does not fall into levels 1, 2 or 3Level 4
Initiate emergency procedures.
Report to: Line Manager/ H&S/EMS Coordinator
Injury likely to result in over 7 day absence
Reportable disease – RIDDOR A minor spill, leak or emission2 into
waterways, land or air
Level 3
CALL333
A specified injury – RIDDOR Dangerous occurrence – RIDDOR A major spill, leak or emission1 into
waterways, land or air An adverse event which could cause
significant damage to the University's reputation
Level 2
CALL333
An employee, contractor, student or member of public is killed
Potential long term/ permanent damage to sites of special scientific interest, protected species or habitat
Level 1
Incident Management plan initiated
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Adverse event
reported to Line
Manager
Adverse report form completed
Adverse report sent
to H&S/ EMS Coordinator
Adverse report form sent to SHE
Health & Safety Policy Arrangements – Adverse Events (Accidents & Incidents) Post Event Reporting
4.2.3 How should an adverse event be reported?
All adverse events including work-related injuries, damage and incidents (not including injury) must be reported by, or on behalf of the person involved to line management as soon as possible after the event occurs.
An
adverse event report should be completed online. The line manager must complete the adverse event report form in full and submit it. Following this the details will be reviewed by SHE and the College/ PSU H&S Coordinator/ Environmental Coordinator who will determine the level of investigation required and discuss with the SHE team.
An adverse event report must be completed online and submitted within 2 days of the event.
If the event is likely to be RIDDOR reportable SHE must be notified within 2 days of the event occurring, even if the member of staff is absent from work. In this instance the adverse event quick e-report can be completed until such time that more details are confirmed or become available about the adverse event.
4.2.4 Reports to enforcing authority
Should there be a requirement to report any adverse event to Natural Resources Wales or the HSE, the SHE team will take responsibility for this.
For further advice or assistance contact the Safety, Health & Environment team via adverseevent@swansea.ac.uk
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Health & Safety Policy Arrangements – Adverse Events (Accidents & Incidents) Post Event Reporting
5. INVESTIGATION
5.1 Why investigate?
Hazards are present in all workplaces. Risk control measures are put in place to reduce risks to an acceptable level to prevent adverse events, dangerous occurences and instances of ill health. The fact that an adverse event has occurred suggests that existing control measures were inadequate.
There are three main motivators:
LEGAL MORAL/ ETHICAL ECONOMICTo ensure the organisation (Swansea University) is operating within the law.
The Management of Health and Safety at Work Regulations 1995 require employers to plan, organise, control, monitor and review H&S arrangemnts. H&S investigations forms an essential part of this process.
The workforce is the heart of a business and their protection is highly important. Every person should leave work at the end of the day without being adversely affected.
Simply, injuries and incidents cost money. Costs associated include sick pay, increased insurance costs, repair costs.
Investigations are undertaken to: understand how and why things went wrong. understand the ways people can be exposed to substances or conditions that may affect
their health get a true snapshot of what really happens and how work is really done. (Workers may
find short cuts to make their work easier or quicker and may ignore rules.) identify deficiencies in risk control management prevent further similar adverse events
5.2 How do I determine the level of investigtion required:
Every adverse event must be investigated. The level of investigation required should be determined by considering the worst potential consequence of the adverse event e.g. an adverse event may not have caused injuries, but had the potential to cause major or fatal injuries, a major spill, release or emission.
5.2.1 INVESTIGATION LEVEL MATRIXMinimal level
Low level
Medium level
High level
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Health & Safety Policy Arrangements – Adverse Events (Accidents & Incidents) Post Event Reporting
Form SHE2 contains the investigation level matrix. This must be completed by the H&S/ EMS Coordinator and returned as part of the adverse event report. It will be reviewed by the Safety, Health and Environment team and the level of investigation and investigation team will be agreed.
Likelihood of recurrence
Potential worst consequence of adverse eventMinor
(Minor H&S; minor environmental)
Serious(Over 7 day
absence RIDDOR Reportable)
Major(Specified injury/ Ill health; Major Environmental)
Death of a person;
Permanent Environmental
DamageCertain
Likely
Possible
Unlikely
Rare
NB: Definitions of ‘consequence’ and ‘likelihood’ are set out in section 1 ‘terms used’.
Risk Minimal Low Medium HighInvestigation level Minimal
levelLowlevel
Mediumlevel
Highlevel
5.2.2 Investigation levels and team make up
Relevant person looks at the circumstances of the event and considers lesson to learn which will prevent recurrence
A team based investigation, involving line managers, SHE Officers, College/ PSU H&S Coordinators/ Environmental Coordinators and
employee representatives. It will be carried out under the supervision of senior management/ directors and will look for the immediate,
underlying and root causes.
The Chair of the SHE Committee will confirm who will be appointed to the team to conduct the investigation.
NB – Fatalities or major accidents are likely to involve external investigation by the Police/ HSE and will be led by the silver/ gold teams
outlined in the Incident Management Plan.
A more detailed investigation by the line manager, SHE Officers, College/PSU H&S Coordinators/ Environmental Coordinators and
employee representatives and will look for the immediate, underlying and root causes. The investigation will be led by the SHE team.
A short investigation by the relevant person(s) into the circumstances and immediate, underlying and root causes of the adverse event, to try
and prevent recurrence and to learn any general lessons
Medium level
Low level
Minimal level
High level
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Health & Safety Policy Arrangements – Adverse Events (Accidents & Incidents) Post Event Reporting
5.3 The Investigation
All investigations must be recorded in writing and a central record will be held by the Safety, Health and Environment team. The investigation forms are attached in appendix 5 and appendix 6. There are key steps in undertaking an adverse event investigation which are outlined below.
Step 1 – Gather Information
Investigations should take place as quickly as possible after an adverse event. Witness statements and photographs of the scene should be included in more detailed investigations.
If viable, more serious adverse events should have the scene preserved. If this causes or could cause significant operational issues, permission should be obtained from senior management and SHE prior to clearing the scene.
All relevant information should be collected including opinions, experiences, observations, sketches, measurements, photographs, check sheets, permits to work and details of environmental conditions at the time.
Step 2 – Analyse Information
The information gathered as part of the investigation should be analysed to determine what happened and why. Consideration as to what information is relevant should be given, together with what information may be missing.
The immediate, underlying and root causes should be identified to learn from past failures and prevent future repetitions.
Consideration must also be given to the factors that can affect work activity including:
Job factors: e.g. work load, working environment, ergonomics Human factors: e.g. competence, skills, risk perception,
Action plan & implementation
Identify suitable risk
controls
Analyse the information
Gather further
information
Arrange & undertake
appropriate investigation
Action plan & implementation
Identify suitable risk
controls
Analyse the information
Gather further information
Arrange & undertake
appropriate investigation
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Health & Safety Policy Arrangements – Adverse Events (Accidents & Incidents) Post Event Reporting
Organisational factors: e.g. work patterns, resources, communication Plant and equipment factors: e.g. maintained, suitable for the work, trained in use
Step 3 – Identify suitable risk controls
The analysis of the adverse event will have identified risk control measures that either failed or that could have interrupted the chain of events leading to an adverse event, if they had been in place.
When considering risk control measures to recommend and their priority, consider them in the following order:
Hierarchy of control
Eliminate the risk Avoid the risk altogether by removing the hazard or no longer undertaking the work activity.
Reduce/ Substitute the risk Reduce the risk by substituting the hazard or activity with one which entails a lower risk.
Isolate the risk Control the risk by physical isolation or separation of people from the hazard
Control the risk Control the risk by procedural methods e.g. safe systems of work, information, training instruction and supervision
Protect the individual As a last resort as it is the lowest level of protection - provision of suitable personal protective equipment
Discipline Ensure that all controls are monitored, reviewed and enforced
Step 4
The investigation must conclude with an action plan for the implementation of additional risk control measures. The objectives must be SMART e.g. Specific, Measurable, Agreed and Realistic with Timescales. Relevant risk assessments will need to be reviewed and updated to reflect the additional control measures outlined.
Action plan & implementation
Identify suitable risk
controls
Analyse the information
Gather further information
Arrange & undertake
appropriate investigation
Action plan & implementation
Identify suitable risk
controls
Analyse the information
Gather further information
Arrange & undertake
appropriate investigation
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Health & Safety Policy Arrangements – Adverse Events (Accidents & Incidents) Post Event Reporting
A copy of the completed investigation report must be sent to the SHE team who will file a copy centrally.
Items within the action plan may need to be discussed with senior management to ensure that adequate resource is allocated to complete actions outlined. Ownership and responsibility for ensuring that the items outlined on the action plan are completed lies with the PSU/ College.
The action plan should deal effectively not only with the immediate and underlying causes but also the root causes;
include lessons that may be applied to prevent other adverse events, eg assessments of skill and training in competencies may be needed for other areas of the university;
provide feedback to all parties involved to ensure the findings and recommendations are correct, address the issues and are realistic;
should be fed back into a review of the risk assessment communicate the results of the investigation and the action plan to everyone who needs to
know; include arrangements to ensure the action plan is implemented and progress monitored.
Not every risk control measure will be implemented, but the ones according to the highest priority should be implemented immediately. The magnitude of the risk (‘risk’ is the likelihood and severity of harm) should guide priorities. A key question to consider is ‘What is essential to securing the health and safety of the workforce today?’ What cannot be left until another day? How high is the risk to employees if this risk control measure is not implemented immediately? If the risk is high, immediate action is required. There will be financial constraints, but failing to put in place measures to control serious and imminent risks is totally unacceptable. Risks must be reduced to as low as reasonably practicable or work must stop. For those risks that are not high and immediate, the risk control measures should be put into the action plan in order of priority. Each risk control measure should be assigned a timescale and a person made responsible for its implementation.
Details of adverse events, investigations and actions plans should be reported on at termly College/ PSU SHE Management Steering groups. In addition College/ PSU SHE Management Steering Groups should ensure that all reports on adverse events are provided to the SHE Committee on a termly basis using the termly report template.
6. RECORDS MANAGEMENT
SHE will maintain an electronic record of all adverse events and investigations involving Swansea University staff, students or property on the Health and Safety Management system.
All adverse event reports and investigations must be held for a minimum of 4 years by University Colleges and PSUs. Records will also be held centrally by SHE for a minimum of 7 years.
The University is committed to complying with the requirements of the Data Protection Act 1998 and any personal data created as part of these arrangements will be processed in accordance with
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Health & Safety Policy Arrangements – Adverse Events (Accidents & Incidents) Post Event Reporting
the University’s Data Protection Policy. This includes ensuring that data is held securely, is not disclosed unlawfully and is destroyed when no longer needed.
7. COMMUNICATION
7.1 Occupational Health
Adverse event reports resulting in an injury at work or potential ill health and resultant investigations will be shared with Occupational Health by SHE. Occupational Health will determine the level of involvement required and issue appropriate reports.
7.2 Dealing with legal claims and solicitors
If any individual is approached by a legal representative, the individual should refer that representative immediately to the Insurance Officer as there is a strict time to respond.
7.3 Dealing with the press or media
If an individual is approached by a representative of the media, they should refer the representative to the University Communications Dept. Individuals should not respond directly to requests from the media for comments or information. All media enquiries must be signposted to:
Jacqui Bowen – Head of Public Relations Jacqui.Bowen@Swansea.ac.uk
and cc’d to the Press Office Press@swansea.ac.uk
8. DATA AND TRENDS
All adverse event reports and investigations will be saved on the University H&S Management system, sharepoint. College/ PSU named personnel will be able to view all adverse events and investigations for their own College/ PSU only. Permissions for access will be authorised by SHE following named nominations by the College/ PSU.
SHE will collate all information relating to adverse events and produce statistical reports which will be shared on a termly basis with College and PSU SHE Management Steering Groups and the SHE Committee.
Data will be analysed to identify trends, benchmark against HSE annual statistics and inform safety campaigns.
The injury prevalence rate will be calculated on a termly and annual basis using the HSE formulae:
IR = Incidence Rate = Injuries (per year) * 1000 Employment
Statistical data will include:
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Health & Safety Policy Arrangements – Adverse Events (Accidents & Incidents) Post Event Reporting
Total Reported accidents Accident Incidence rate RIDDOR incidents:
o Injurieso Diseaseso Dangerous Occurrences
Injury by person Injury type Injury by age
9. FATAL INCIDENCE PROTOCOL
Fatalities are classed as a level 1 adverse event and 333 should be dialled immediately. The Incident Management Plan will be initiated to coordinate and manage the event.
6. Safety, Health & Environment (SHE) Services Role
In addition to the tasks demonstrated within the Health and Safety Policy, SHE Services will also provide the following support to assist in the management of Adverse Events (Accidents & Incidents):
Guidance, advice and support in what should be reported and in completing investigations Training for staff involved in undertaking adverse event investigations Generation of statistical data Reporting adverse events to the HSE and Natural Resources Wales.
7. Appendices
Appendix 1 Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013
Appendix 2 Quick report form
Appendix 3 Adverse event report form
Appendix 4 Investigation matrix
Appendix 5 Minimal/ low level adverse event investigation form
Appendix 6 Medium/ High level adverse event investigation form
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APPENDIX 1Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013
The University must ensure that it complies with the regulations to report any notifiable injuries, diseases or dangerous occurrences. Further guidance on what injuries, diseases and dangerous occurrences are included within the regulations can be found on the HSE website: http://www.hse.gov.uk/riddor/
Guidance document INDG453 ‘Reporting accidents and incidents at work - A brief guide to the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR)’ provides more information on what should be reported in work.
The SHE team will ensure that all reports are submitted to HSE. It is important however that adverse events which may be notifiable under the RIDDOR regulations are submitted to SHE within 4 days of the event occurring.
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Health & Safety Policy Arrangements – Adverse Events (Accidents & Incidents) Post Event Reporting
APPENDIX 2QUICK REPORT E-FORM
A quick report can be made via the SHE website. The form consists of the fields outlined in the screen shot of the report below:
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Health & Safety Policy Arrangements – Adverse Events (Accidents & Incidents) Post Event Reporting
APPENDIX 3ADVERSE EVENT REPORT FORM
Section A About the incidentWhat is being reported?:
Choose an item. Date: Time:
Campus: Choose an item. Building Name/ Area:
Building Floor: Location e.g. room number
Brief details (What, where, when, who and emergency measures taken):
Details of injury (Person):
First Aid administered:
Damage (Equipment/ Property/ Habitat):
Witnesses (Name, Occupation and Tel No):
Section B Who was involved in the accident/ incidentFull name: Age &
DOB:Occupation/ Course of study (if student):
Job Title:
University College/ PSU or Employer:
Email:Tel:
Line Manager Name
LM Tel/ Email:
Status: ☐ EmployeeID no:
☐ StudentID no:
☐ Visitor ☐ Contractor ☐ Other (specify)
Address: (Visitor/ Contractor/ Other)
Has the incident resulted in an absence from work?
Yes No
Reported by: Job title:
Tel: Email:
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Health & Safety Policy Arrangements – Adverse Events (Accidents & Incidents) Post Event Reporting
Date:
APPENDIX 4INVESTIGATION MATRIX
SHE2
Type of event Actual/ potential for harm
Accident Fatality/ Permanent Environmental Damage
Incident – Near Miss Major
Incident – Environmental Minor
Dangerous occurrence Damage only (Equipment/ Building)
Fire
RIDDOR/ NRW reportable? Y/N Date & time reported (SHE only)
Entry into accident records Y/N Date entered & reference
Investigation level
High level Low levelMedium level Basic
Initial assessment carried out by
Initial assessment carried out by: Date:
For completion by SHE:
Further investigation required: Y/ N Priority:Investigation team:
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Health & Safety Policy Arrangements – Adverse Events (Accidents & Incidents) Post Event Reporting
APPENDIX 5Date of event: Event report ref:
Name of responsible manager:Name dept. H&S/Environment Co-ordinator:Name(s) of person(s) investigating incident:
Job role: Dept:
Investigation date:MINIMAL/ LOW LEVEL ADVERSE EVENT INVESTIGATION FORM
About the person affected/ involvedName: College/
PSU:Contact details: Tel: Email:
Date of adverse event
Time of event
Location (Building/ Room)
Who was injured/ suffered ill health or was otherwise involved in the adverse event? What injuries or damage occurred?
How did the adverse event happen?
What activities were being carried out at the time?
Further comments
Was there anything unusual or different about the working conditions?
Yes ☐ No ☐
Were there adequate safe working procedures and control measures in place?
Yes ☐ No ☐
Were the people involved competent and suitable?
Yes ☐ No ☐
Did other conditions influence the adverse Yes ☐ No ☐
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Health & Safety Policy Arrangements – Adverse Events (Accidents & Incidents) Post Event Reporting
event?
What do you think contributed to the incident?
Equipment factors –
Human factors –
Job factors –
Organisation factors -
Immediate causes:
Underlying root cause:
Root cause:
Has the risk assessment/ safe working procedure for the activity been reviewed following the incident?
RISK CONTROL ACTION PLANCONTROL MEASURES BY WHO TIMESCALE DATE
COMPLETED
Signature of responsible manager:Signature of Dept. H&S Coordinator:
Section for use by SHE team
Receiving Adviser: Date:RIDDOR Reportable? RIDDOR Ref: Date:Environmental report necessary (NRW/ Dwr Cymru)Date report passed to OH:
Date report passed to Insurance Administrator:
Date investigation report returned:
Further action required?:
Supporting photos:
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Health & Safety Policy Arrangements – Adverse Events (Accidents & Incidents) Post Event Reporting
APPENDIX 6MEDIUM /HIGH LEVEL INVESTIGATION FORM
Date of incident: Incident report ref:
Name of responsible manager:Name dept. H&S/Environment Co-ordinator:Name(s) of person(s) investigating incident:
Job role: Dept:
Investigation date:
About the person affected/ involvedName: College/
PSU:Contact details: Tel: Email:
Where and when did the adverse event happen?
Who was injured/ suffered ill health or was otherwise involved in the adverse event?
How did the adverse event happen?
What activities were being carried out at the time?
Was there anything unusual or different about the working conditions?
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Health & Safety Policy Arrangements – Adverse Events (Accidents & Incidents) Post Event Reporting
Were there adequate safe working procedures and control measures in place? Were they followed? (RA, training, maintenance, permit to work, PPE etc)
What injuries, ill health effects or damage, if any, were caused?How did it occur and what caused it?
Was the risk known? If so, why wasn’t it controlled? If not, why not?
Did the organisation and arrangement of the work influence the adverse event?
Was maintenance and cleaning sufficient? If not, explain why not.
Were the people involved competent and suitable?
Did the workplace layout influence the adverse event?
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Health & Safety Policy Arrangements – Adverse Events (Accidents & Incidents) Post Event Reporting
Did the nature or shape of the materials influence the adverse event?
Did difficulties using the plant and equipment influence the adverse event?
Was the safety equipment sufficient?
Did other conditions influence the adverse event?
What do you think contributed to the incident?
Equipment factors –
Human factors –
Job factors –
Organisation factors -
Immediate causes:
Underlying root cause:
Root cause:
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Health & Safety Policy Arrangements – Adverse Events (Accidents & Incidents) Post Event Reporting
Has the risk assessment/ safe working procedure for the activity been reviewed following the incident?
RISK CONTROL ACTION PLANCONTROL MEASURES BY WHO TIMESCALE DATE
COMPLETED
Signature of responsible manager:
Signature of Dept. H&S Coordinator:
Section for use by SHE team
Receiving Adviser: Date:RIDDOR Reportable? RIDDOR Ref: Date:Environmental report necessary (NRW/ Dwr Cymru)Date report passed to OH:
Date report passed to Insurance Administrator:
Date investigation report returned:
Further action required?:
Supporting photos:
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