Management of an incident

Question 1

What are the broad aims of managing an incident?

Answer 1

Manage primary incident

Minimise risk to further incidents

Prevent future incidents

Question 2

What are the initial steps to manage the primary incident?

confirm details of the incident

Answer 2

1. Confirm details of incident
   Verify diagnoses if there has been an infection caused

Baseline assessment of the incident

Assessment of probability of recurrence to help assess level/detail of
investigation and more immediate action required

Detection of incident-how long it progressed before identification

Notify Trust Risk manager/clinical governance lead as a:
‘near miss’ / ‘incident’ / ‘SUI’ as appropriate

Question 3

What are the initial steps to manage the primary incident?

put in emergency measures

convene meeting group

Answer 3

2. Put in emergency measures
   Manage case/s

Temporary hold on use of instrument or current practice–may need to hold operations but balance risk/benefit of decision

Remove any obvious problem

3. Convene Incident Group
   DIPC
   Consultant Microbiologist (may be the DIPC)
   (ICNs)
   Lead consultant for the clinical area & affected patients
   Ward manager/Senior nurse e.g. theatre sister

If serious–medical director
Chief executive/nominated officer
Administrative and clerical support

If surgical– Anaesthetic consultant, lead surgeon, ODA manager

If sensitive/serious/media interest– Communications officer

Question 4

What are the initial steps to manage the primary incident?

Gathering information about the event/ cases

Answer 4

4. Investigation
   (i) Event
   Establish full details of the incident as soon as possible and ideally within 72 hours– hindsight bias
   Interviews of all staff involved

What did they expect should have happened?
What happened?
Why was there a difference?
What was the effect of the incident on patient / others
At what point was it identified
Severity rating of incident

(ii) Case find
–other breaches resulting in SUI
morbidity/mortality

And consider how long it took for this incident to come to light

Question 5

What are the initial steps to manage the primary incident?

root cause analysis

Answer 5

Consideration of the fundamental issues that lead to the incident
Detection of incident
Contributory factors
Root causes
Lessons
learned

Question 6

What are the initial steps to manage the primary incident?

Initial remedial measures to

Answer 6

Directed by risk assessment of process & clearly linked to RCA
findings:

Identify the hazard

Decide who might be harmed /how it can go wrong

Evaluate risks and decide on precautions

Address all issues in the event description and route cause analysis

Should significantly reduce chance of recurrence

SMART objectives about the incident
Specific
Measurable
Achievable
Realistic
Timely
And
Specific

Decontamination as necessary

Staffing–education & training

Controlling procedures pending remedial action

Other specific control measures directed at cause

Communication–to all relevant including patient and relatives

Question 7

After an incident, ongoing management is required to ensure further episodes do not occur

What ongoing management steps are required?

Answer 7

Surveillance for further cases

Specialist advice if necessary

Further incident team meetings:

Membership

Control measures in place

Action points planned with clarity of roles

Communication

Preliminary and follow up reports

Question 8

After an incident, when is an incident closed?

Answer 8

After a period of enhanced monitoring without any new cases

Final report issued