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

2. 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

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

4. Policy Framework NHS Improvement
National Reporting and Learning System
Serious Incidents
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.
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)

5. Cont: Public Health England
Guidance on vaccine potency and quality to ensure credibility of vaccine programme
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

6. 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

7. 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

8. 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)

9. 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

10. Support:
Paula Evans Primary Care Quality Improvement Lead. (NHS South Kent Coast and Thanet CCGs) Mobile: Debbie Dunn Primary Care Nursing & Quality Lead (Canterbury & Coast and Ashford CCGs) Mobile: Esther Taborn Head of Infection, Prevention & Control Mobile: Susan Roots Quality Lead for Infection, Prevention & Control Mob: Local PHE South East Phone:

11. Thank you and any questions??