Serious Incident Management in Primary Care

Serious Incident Management in Primary Care

Summary of Incident

For Example: SI1 Form (see enclosed)

Mid-Notts CCG Serious Incident Notification Form

GP Practice Details
Name of GP Practice:
CCG
Name of Practice Manager
Reporter Details (person completing the form)
Name of Reporter:
Job Title:
Email:
Tel: / Date of notification:
Serious Incident Details
NHS Number of patient affected (if applicable)
Are affected people aware of the Serious Incident (duty of candour)?
Date / Time of Serious Incident
Description of Serious Incident/what happened
Immediate Actions Taken
Was any other agency involved in the Serious Incident? Have any other agencies been informed? (eg. another provider / safeguarding team)

Send Completed Form To

Planning the Investigation

Steps / Timescale
Review the incident – understand the full scope of the problem
Alternative Hypotheses - think broadly aboutthe incident, avoid jumping to obvious conclusions, think of all the possibilities that could have led to the incident happening
Collecting the information – 4 Ps (People, Paper, Places & Parts)
Tabular Timeline – populate with the 4P’s
Analysis - Wagon Wheels / Fishbone / Tom Jones
Write the report - Cut and paste into the template

Index of Information

Doc / Provider And Agreed Time Limits / Telephone Number / Date Chased / Received / Reviewed
People
(E.g. Statements)
Paper
(E.g. Documentation Inc. Electronic records)
Place
(E.g. Photographs)
Parts
(E.g. Equipment)

Tabular Timeline (Word)

Mapping the Information:

Information about each event is likely to be contained in many different documents (protocols, statements etc.) The tabular timeline pulls the information together and organises it.

For a serious untoward incident

Event Number / Date / Time / Description of event / Who was involved / Details / Any missing information? / Things that have gone to plan / Care Delivery Problems (Things that haven’t gone to plan)

Wagon Wheels

Prepare wagon wheels

Contributory Factor

CDP

Contributory Factor

System

System

.

System

Contributory Factor

Recommendations

1.

2.

3.

4.

5.

Fishbone Classification – Contributory Factors

This fishbone diagram will assist you to identify contributory factors.

For disciplinaries and employment grievances you will be looking at potential defences.

Edd

Serious Incident Root Cause Analysis Report

Organisation Name / Insert the name of your organisation
Date of incident
Date incident reported
Incident Reference Number / Any reference number within your own incident data base- or STEIS number
Author of Report
Contributor(s) to the report / Anyone who was involved in the investigation
Version

Summary incident description and consequences

What happened, when and how did it affect the patient. Severity of the incident

Investigation Methodology

How the investigation was undertaken. Scope of investigation Include any terms of reference you may have

Limitations to the report

What information could you not find and why. If you have requested information from another provider but did not get this you need to write about your efforts to obtain that information

Duty of Candour

How have you communicated with the person affected and or their family, have they been given a point of contact, have you apologised are you including the families questions in your investigation

Support for Staff

Include this section if any staff members involved

Root cause(s)

There may be more than depending on what you finding, (CQC) like to see that you have identified a root cause

Care Delivery Problems

This is where you add what you have identified as CDP’s you may want to set them out as Missing Systems, Inadequate Systems

Recommendations

From your Care Delivery Problems you make a recommendation for each missing system / failing system (if you can number them to match up with your Care Delivery Problems this is helpful)

Arrangements for shared learning

Appendix 1 Tabular Time Line

Appendix 2

Add in appendices such as chronology, photo’s statements.

Action Plan

Care Delivery Problem / Recommendation / Action / Action Owner / Date Due / Date Completed

You may not do an action for every recommendation but if you are not you should add a section explaining why you are not able to implement any recommendations.

V1 Oct 16