Incident Reporting and Investigation Policy...Incident Reporting and Investigation Policy Website: Email: [email protected] will request further information where

South West Neonatal Network Policy Incident Reporting and Investigation Policy

November 2018

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South West Neonatal Network Guideline Incident Reporting and Investigation Policy

Website: www.swneonatalnetwork.co.uk Email: [email protected]

INCIDENT REPORTING FLOW CHART 3

1. BACKGROUND 0

2. INTRODUCTION 0

3. PURPOSE 0

4. SCOPE 0

5. GOVERNANCE AND REPORTING MECHANISM 0

6. STANDARDISED REPORTING SYSTEM FOR NETWORK INCIDENTS 1

7. PROCESS ERROR! BOOKMARK NOT DEFINED.

REPORTING 2

APPROVAL PROCESS 2

DISSEMINATION 3

8. COMMUNICATION GOVERNANCE IN THE SWNODN (APPENDIX FIVE) 3

9. REDUCTION OF SERVICE/FULL OR PARTIAL CLOSURE OF A SW NEONATAL SERVICE. 3

10. COMMUNICATION WITH THE FAMILY 4

11. REFERENCES 4

APPENDIX ONE 5

SW NEONATAL NETWORK CLINICAL INCIDENT NOTIFICATION FORM 5

APPENDIX TWO 6

LOCAL INCIDENT INVESTIGATION TEMPLATE 6

APPENDIX THREE 8

SW NEONATAL NETWORK CLINICAL INCIDENT – FINAL REPORT 8

APPENDIX FOUR 11

http://www.swneonatalnetwork.co.uk/

mailto:[email protected]

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COMMUNICATION GOVERNANCE FLOW CHART 11

APPENDIX FIVE 12

COMMUNICATION PRO-FORMA 12

APPENDIX SIX 13

SW NEONATAL NETWORK CLINICAL INCIDENT SUMMARY OF LEARNING 13



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Incident Reporting Flow Chart

Neonatal Service identifies infant/event meeting

incident reporting criteria

Complete SWNODN Incident Reporting Form (Appendix One) return to [email protected]

Investigation team agreed within Two Weeks. Local investigation template

circulated by Network Team.

Investigation to be fully completed within 30 days, where possible.

Final Report Complied by Network Lead Nurse and circulated to Local Lead Clinician/Lead

Nurse/Governance Lead for factual accuracy checking

Network Clinical Director and Lead Nurse assess the report and recommendations.

Re-Circulate to Investigation team

Network Lead nurse to compile incidents/investigation for circulation to

Advisory and Governance Board for review, shared learning, agree

dissemination

Network Lead nurse to present incident/investigations at SWNODN Exec Board and produce quarterly reports for

Specialist Commissioners.




1. Background The South West Neonatal Operational Delivery Network (SWNODN) comprises of twelve neonatal units. Whilst all trusts have systems in place for reporting incidents and mortality these are not well documented at a network level. This guideline articulates the process standardising the approach around how Network Incidents, SUIs, Never Events and Mortality reviews are reported into the SWNODN.

Learning lessons from incidents requires timely incident reporting, which in turn requires a fair, open, and just culture that rejects blame as a tool. In part this is because: “…a patient safety incident cannot simply be linked to the actions of the individual healthcare staff involved. All incidents are also linked to the system in which the individuals were working. Looking at what was wrong in the system helps organisations to learn lessons that can prevent the incident recurring.” National Patient Safety Agency1

2. Introduction The SWNODN is committed to supporting the delivery of high quality, safe and effective neonatal care across the South West. Organisations that have an effective system for reporting, reviewing and learning from adverse incidents and mortality are more able to respond to improve the quality of care and patient safety2. The SWNODN’s aim is to support high quality care that is safe, effective and person-centred. This is a complex system and adverse events occur that do, or could have, a major effect on the parents, babies and people involved. Each of these events should be regarded as an opportunity to learn and to improve in order to increase the safety of care for everyone and to provide a consistent neonatal network approach to the identification, reporting and review of adverse events, and allow best practice and shared learning to be actively promoted across the SWNODN.

3. Purpose To ensure there is a robust procedure for shared learning and improve risk management strategies across the SWNODN. This document contributes to the SWNODN Governance Framework and ensures compliance with national standards described in the Department of Health Toolkit for High Quality Neonatal Services (2009).3 It also ensures that as a Operational Delivery Network we are able to meet our mandated responsibilities of strategic operational oversight for NHSE Specialised Commissioning.

4. Scope This guideline applies to all neonatal units and their teams and transport teams within the South West Neonatal Network.

5. Governance and Reporting Mechanism It is important that the SWNODN has a robust mechanism for reporting and responding to critical incidents and events. The role of the SWNODN is to provide a forum to facilitate clinically led discussions to ensure lessons are being shared across the region. The SWNODN



will request further information where necessary, this must be clear to all providers in the SWNODN.

Each Advisory and Governance Board, held tri-annually, will take an individual focus; reviewing Morbidity, Mortality and Incident Reporting on a rolling annual basis.

An annual report, reviewing trust clinical incidents, will be compiled by the Network Team

from individual trust Annual Governance Reports. This will facilitate the identification of

regional trends and support the work planning of the Network Team for the following year

this will inform;

o Network risk register o Guideline development o Regional education plans o Regional workforce planning

6. Standardised Reporting System for Network Incidents 6.1 Incidents that trigger a network incident report are outlined below and in Appendix

One.

Network Incident type

1. Transfer of baby out of SW Network due to lack of capacity (In or Ex Utero)

2. Delay in transfer of a baby for uplift in care due to receiving units capacity

A. Surgical/Cardiac Uplift

B. Any other

4. Delay in repatriation of infant due to receiving units capacity

5. Transfer undertaken by local unit team

6. Delay in transfer of infant due to lack of transport service capacity

A. Uplifts and Intensive Care > 6hrs generates incident report

B. Planned moves or Repatriations >24hrs with no plan in place generates incident report

7. Closure/partial closure/reduction of service of a neonatal unit or transport service

8. Infant born in the incorrect level of unit for gestational age

9. Other (Incidents trusts would like to submit for shared learning purposes or which require communication support from the Network Team)

6.2 It will be responsibility of the each unit to complete a Network Incident Form for all

infants/events meeting the criteria outlined above and in Appendix One. 6.3 On a monthly basis the Network Team will circulate a list of infants that meet the

following specific incident reporting criteria (Appendix One) who have been entered into Badger but for whom a completed incident form has not been received:





Infant born in the incorrect level of unit for gestational age (Units will be required to complete a Network incident form retrospectively for each of the incidents).

6.4 All incidents and communication queries will be coordinated by the Network Lead Nurse (NLN). The NLN will prepare all data with support from the Data Team and report to the Advisory and Governance Group. Where shared learning is identified the NLN will ensure this is disseminated across the SWNODN.

6.5 It will be the responsibility of the Local Lead Nurse, Clinician or Risk Lead to discuss the contents of their Trust’s report, providing a brief summary and identified learning points at the Advisory and Governance meeting, ideally by the local team, but otherwise by the Network Team.

6.6 Issues related to service delivery including patient flows and/or pathways or that have a wider bearing on the SWNODN will be considered by the Neonatal Network Executive Board. The Network Lead Nurse will produce a 4 monthly report for The Advisory and Governance Board, and Executive Board detailing data and shared learning from the previous quarter.

6.7 Voluntary reporting of incidents – a) Units to share anonymised outcomes of trust based route cause analysis or other

investigations where the clinicians/ trust feel there is shared learning which

should be disseminated across the region (see 6.10)

6.8 Reporting

1. A copy of the network incident notification form should be sent to the Network Lead Nurse (see Appendix One)

2. Within two weeks of the incident being reported, the local unit should have agreed the scope of the investigation and details of the investigating team.

3. The Local Investigation template, (See Appendix Two) should be used as the investigation template.

4. The investigation and recommendations should be completed and returned to the Network lead nurse within 30 working days (Complex investigations may require longer time frames – to be discussed with the Network Lead Nurse).

5. Findings will be summarised by Network Lead Nurse onto the form in Appendix Three which will result in the generation of a final report and agreed action plans.

6. These should be forwarded to the Network Manager, relevant Lead Clinicians/ Matron and Network Lead Nurse for approval.

6.9 Approval Process

1. The clinical governance lead or Lead Clinician from each of the involved teams or units should agree that it is factually correct.

2. The Network Clinical Director and the Network Lead Nurse should then assess the report.

3. Each recommendation should be assessed for (a) likelihood of reducing the possibility of a similar incident occurring and (b) feasibility/affordability.

4. If a recommendation is rejected then the reason should be clearly documented 5. If a recommendation is accepted then a named individual should be documented as

responsible with the date for implementation agreed.





6. This should then be presented to the next network Advisory and Governance Board and Executive Board, ideally local teams will present their own incidents and actions, the ODN can oversee / support or present in the event of non-attendance.

6.10 Dissemination

Once an investigation of an incident is complete and key learning points clarified, the Network Lead Nurse will complete a Summary of Learning form (Appendix Six) which will be utilised when disseminating learning across the Network. The form will remain anonymised and contain no patient/staff/incident identifiable details ensuring it remains a standalone learning tool. There are a number of ways in which learning from incidents may be disseminated within the SWNODN to improve patient safety and reduce the risk of recurrence. Examples of communication methods might include but are not limited to:

At Neonatal Working Groups

At Advisory and Governance Board

Newsletters

SWNODN website

Email Circulation

Reports to the Neonatal Network Executive Board

Reports to the Specialist Commissioners/Supplier Managers

7. Communication Governance in the SWNODN (Appendix Five) In situations where a provider would like the SWNODN to raise a query with another provider/or multiple providers in the SWNODN the Network Team will act as an honest broker. A communication pro forma is completed and returned to the Network Lead Nurse. Current research indicates that ineffective communication among health care professionals is one of the leading causes of medical errors and patient harm7. The SWNODN adopts an SBAR technique to answer the questions raised, including the recommendation about what action is required (Appendix Six)

The Network Lead Nurse forwards the communication pro forma to from Unit A to Unit B; who are expected to respond within three weeks of the request. At any point the SWNODN has concerns about care or service delivery this will result in escalation.

9. Reduction of Service/Full or Partial closure of a SW Neonatal

Service. This policy should always be read in conjunction with the SWNODN Closure Policy (available on SWNNODN Website). All reduction of service/full or partial closures to any Neonatal Service within the South West Neonatal ODN is subject to escalation to the Network Team via Clinical Incident Notification Form.





10. Communication with the family If the incident involves a patient, the family should be told clearly about the incident and the process for investigation explained. The family will be given a named contact at the unit who has instigated the investigation process (usually either a Lead Nurse or Lead Clinician) who will be their single point of contact. This single point of contact will then liaise with the Network lead Nurse, who will be responsible for ensuring the process is completed in a timely manner, for updates on the process and to arrange a review meeting to discuss the outcome of the investigation. The family will be informed that the Network lead Nurse will have oversight of the process and in the event of any concerns or complaints about the investigation process they should be given the Network Lead Nurse’s contact details. The parents should be given a full copy of the report, unless there are overriding issues (such as child protection concerns or confidential information relating to a third party other than the baby). In these rare cases the parents should be given a redacted report.

11. References

1. National Patient Safety Agency, ‘Seven Steps to Patient Safety’’, 2004 – 2009. Available at http://www.nrls.npsa.nhs.uk/resources/collections/seven-steps-to-patient-safety/

2. A Promise to Learn-a commitment to Act. Improving the Safety of Patients in England. D. Berwick DH 2013 https://www.gov.uk/government/publications/berwick-review-into-patient-safety

3. Toolkit for High Quality Neonatal Services Department of Health 2009 https://www.nepho.org.uk/uploads/doc/vid_8769_Toolkit%20for%20high-quality%20Neonatal%20services.pdf

4. NHS England (2015) Serious Incident Framework available online: https://www.england.nhs.uk/patientsafety/wp-content/uploads/sites/32/2015/04/serious-incidnt-framwrk-upd2.pdf

5. NHS England (2015) Revised Never Events Policy and Framework Available online: https://improvement.nhs.uk/uploads/documents/never-evnts-pol-framwrk.pdf

6. NHS England National Patient Safety Alerting System. Available online: https://www.england.nhs.uk/patientsafety/wpcontent/uploads/sites/32/2014/01/npsas-guide2.pdf 4

7. A Promise to Learn-a commitment to Act. Improving the Safety of Patients in England. D. Berwick DH 2013 https://www.gov.uk/government/publications/berwick-review-into-patient-safety



https://www.nepho.org.uk/uploads/doc/vid_8769_Toolkit%20for%20high-quality%20Neonatal%20services.pdf

https://www.nepho.org.uk/uploads/doc/vid_8769_Toolkit%20for%20high-quality%20Neonatal%20services.pdf

https://www.england.nhs.uk/patientsafety/wp-content/uploads/sites/32/2015/04/serious-incidnt-framwrk-upd2.pdf

https://www.england.nhs.uk/patientsafety/wp-content/uploads/sites/32/2015/04/serious-incidnt-framwrk-upd2.pdf

https://improvement.nhs.uk/uploads/documents/never-evnts-pol-framwrk.pdf

https://www.england.nhs.uk/patientsafety/wpcontent/uploads/sites/32/2014/01/npsas-guide2.pdf%204

https://www.england.nhs.uk/patientsafety/wpcontent/uploads/sites/32/2014/01/npsas-guide2.pdf%204

https://www.gov.uk/government/publications/berwick-review-into-patient-safety



Appendix One

SW Neonatal Network Clinical Incident Notification Form

Network Incident type Tick

1. Transfer of baby out of SW Network due to lack of capacity (In or Ex Utero)

2. Delay in transfer of a baby for uplift in care due to receiving units capacity

A. Surgical/Cardiac Uplift

B. Any other

A

B

4. Delay in repatriation of infant due to receiving units capacity

5. Transfer undertaken by local unit team

6. Delay in transfer of infant due to lack of transport service capacity

7. Closure/partial closure/reduction of service of a neonatal unit or transport service

8. Infant born in the incorrect level of unit for gestational age

9. Other (Incidents trusts would like to submit for shared learning purposes or which require communication support from the Network Team)

Incident being investigated locally Yes / No

Incident Reported by -

Name and Title: Date:

Organisation: BadgerNet number of infant involved:

Brief outline of incident and outcome:

Contacts at other hospital

Consultant:

Nurse:

Telephone/Bleep:

Telephone/Bleep:

Has this Incident been referred for clinical governance procedures in another perinatal network or

Neonatal Transport Service? Yes / No

If yes, please specify which:

Date received by Network Clinical Lead / Governance Lead .................................................





Appendix Two

Local Incident Investigation template

Incident identification reference (Incident date + Reporting Unit Name):

Date/Time/Location of

Incident including hospital /

ward / team level

information

Incident type

Description of incident*

including reason for

admission and diagnosis

Details of contact with or

planned contact

patient/family or carers

Immediate actions taken

including actions to mitigate

any further risk

Details of other

organisations/individuals

notified

Commissioner Informed?

Date:

Name of individual notified:

Root cause of incident

Contributory factors





Lessons learned

Recommendations

Date / time report

completed

Report author





Appendix Three

SW Neonatal Network Clinical Incident – Final Report

No Demographic Information Answer

1 Incident identification reference (Incident date + Reporting Unit Name)

2 Date of Incident

3 Describe actual event

4 Has a similar event occurred before in the organisation or network?

If yes to Q4 note the most recent date of a similar event occurring

If yes to Q4 was an incident analysis conducted?

If incident analysis was conducted please list the recommendation which were agreed:





List the recommendations which were not approved

5 Incident structure answer

Date final report is due (max 30 working days from incident unless agreed to be longer with ODN lead nurse)

Date incident review actually completed

6 Attachments (final understanding of events) This is the team’s final interpretation of the factual information. It should include

a) The chain of events b) The contributing factors c) An action plan table (see examples).

This should enable external reviewers to understand the sequence of events and demonstrate why the associated recommendations have been developed.

7 Effectiveness of previous solutions. - If a similar event has happened before did the

recommended actions minimise the severity or extent of the adverse event?

Yes/no

If so – how

8 Lessons learnt There may be other system vulnerabilities that the incident team identified during the incident process. If these have been identified, but did not have a causal effect on the incident itself document here.





9 Contributing Factors – list any identified by the incident team

Comments

Human Factors - communication

Yes/no

Human factors - training

Yes/no

Human factors – fatigue/scheduling

Yes/no

Environment/equipment

Yes/no

Rules/policies/procedures

Yes/no

Barriers

Yes/no

10 Incident agreement. List all investigation team members and ensure that they sign the form.

Name Signature Title Date





Appendix Four

Communication Governance Flow Chart

NNU A or transport service raising a query NNU B or transport service receiving the query

Query raised by Clinical Lead/Lead Nurse raise query using pro forma (Appendix Six) and

returned to Neonatal Lead Nurse and/ Network Clinical Director

Network Lead nurse logs query and

assigns reference number

Network Lead nurse raises query

with Clinical Lead/Nursing Lead

Unit B

Clinical Lead/Nursing Lead

investigates and generates a

response to Network Lead

Nurse/Network Clinical Director

Network Lead nurse and Network Clinical Director assess response, generate recommendations

or need for further discussion or information.

Network Lead nurse and Network

Clinical Director make simple

recommendations

NNU A & B accept response and

recommendations - Closed

Network Lead nurse/Network Clinical director request

further information/discussion from NNU A and B

NNU A &/B Clinical Lead response to Network Lead

Nurse and Network Clinical Director

Network Team Assess Response

If further consideration is required escalate to South West Advisory and Governance Board for

review, lessons learned and actions utilising summary of learning form.





Appendix Five

Communication Pro-forma

South West Neonatal Operational Delivery Network Communication Pro-

forma

Neonatal Unit A Query

Query From Unit: Name:

Query To:

Description A: Situation:

Background:

Action:

Recommendations

Date Received (Network Office):

Date Forward: (Network Office)

Response Neonatal Unit B:

Name:

Details (Unit B):

Date Received (Network Office):

Date Forward

(Network Office):

Status Unit A (Please Indicate):

Accept and Close Request Further

Information

Request Network

Discussion





Appendix Six

SW Neonatal Network Summary of Learning

Incident identification reference: Report Date: Lessons Learned:

What were the events that allowed the incident to occur?

Details of any processes that failed?

Other actions that should have been taken, but were not? Do not enter any patient or staff or unit identifiable details Actions Taken:

What measures have been put in place to militate against this happening again?

Has any training been undertaken or communication sent out?

Details of any new processes or procedures implemented as a result of this incident?



Documents

Incident Reporting and Investigation Policy...Incident Reporting and Investigation Policy Website: Email: [email protected] will request further information where