Reporting and Learning from Incidents Susan Roots Quality Lead for IPC East Kent CCGs

Objectives: Develop an understanding of Incident Reporting Demonstrate knowledge of the process To know why it is necessary to report incidents Barriers to reporting To be able to conduct an investigation To understand where to access support

What is Investigation Reporting? Policy Framework Best Practice Learning from incidents

Policy Framework NHS Improvement National Reporting and Learning System https://improvement.nhs.uk/documents/815/gp-nrls-guide.pdf Serious Incidents https://improvement.nhs.uk/resources/serious-incident-framework/ Care Quality Commission Expectation of safe care and will look at the practice’s processes and systems to monitor patient safety through reporting patient safety incidents and the practice’s learning from these incidents and significant events. http://www.cqc.org.uk/guidance-providers/gps/nigels-surgery-24-reporting-patient-safety-incidents-national-reporting NHS I – not mandatory to report but is best practice NRLS – all incidents; since 2003; e-form to make it easier; anyone can report;can be anonymous; Serious Incidents – specific criteria (Commissioning nhs funded services only at present) ie reporting and investigating (RCA)

Cont: Public Health England Guidance on vaccine potency and quality to ensure credibility of vaccine programme https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/326417/Vaccine_Incident_Guidance.pdf Clinical Commissioning Group advice and guidance on how to report and incident and when in doubt Serious Incident Framework shared with all Practices In-house policies Every GP Practice should have an Incident Policy to include framework, process, investigation and learning (Action Plan) Evidence of learning from incidents

Best Practice Since NRLS developed more than 1.5 million reported annually Majority are No Harm incidents Anyone can report an incident Learning how to investigate may need further training or support (depends on level of investigation) Better to report than not to – transparency Identify source or Root Cause Trends/themes (audits) No Harm - Any unexpected or unintended incident which was noticed and halted or reversed before it was able to cause harm to a patient ie drug prescribed by not issued by pharmacist

Barriers to Reporting Historically thought of a ‘Blaming Culture’ New process Additional time Technology (form on-line) Identifying an investigator Training Writing a policy Implementing change (process, colleagues, learning, patients) Teaching colleagues and raising awareness Being open and transparent (Practice taking responsibility) Notifying CCG, NHSE, CQC

Learning from Incidents Look at Nigel’s surgery ‘Myth Busters’ In-house learning to improve practice Action Plans – share with colleagues (evidence for CQC) Regular item on clinical agenda to share learning and implement change into practice (evidence for CQC) Shared learning with colleagues ie clinical supervision; group of practices; other clinicians Across providers (community, acute, pharmacists) Patient Safety Alerts (national)

Summary Looked at different levels of incident reporting National and local frameworks Levels of reporting Why we should report and investigate Who can report Benefits of reporting evidence

Support: Paula Evans Primary Care Quality Improvement Lead. (NHS South Kent Coast and Thanet CCGs) Mobile: 07985 451622 Paula.evans12@nhs.net Debbie Dunn Primary Care Nursing & Quality Lead (Canterbury & Coast and Ashford CCGs) Mobile: 07920 768041 Debbie.dunn@nhs.net Esther Taborn Head of Infection, Prevention & Control Mobile: 07774 332095 Esther.taborn@nhs.net Susan Roots Quality Lead for Infection, Prevention & Control Mob: 07770610063 s.roots@nhs.net Local PHE South East Phone:01233 658405 phst@nhs.net

Thank you and any questions??