Patient Safety:Incident reporting, reflecting and learning

Question 1

What is the adverse events iceberg?

Answer 1

Unnoticed errors → near misses/good catches → errors considered insignificant → errors that could cause harm → serious errors

Question 2

What is the form called that is filled in when an incident happens?

Answer 2

Incidence form

Question 3

What are the 5 types of incidence that can occur?

Answer 3

Clinical incidents - Related to planning, organisation, delivery of care, treatment or procedures
Patient incidents- Non treatment related e.g. slip, trip, fall
Security incidents - E.g. Theft of property, violence or aggression
Staff incidents - E.g. Slips, trips, verbal/physical abuse, exposure to hazardous substances
Information Governance incidents

Question 4

What is used to calculate the level of risk if an incident was to happen?

Answer 4

risk matrix

Question 5

What is a near miss?

Answer 5

Harm Event did not happen due to discovery (and action) or by chance
Harm prevented but potential could still exist and needs to be managed

Question 6

What is the 4 step process to manage clinical risks?

Answer 6

Identify the risk
Assess the frequency and severity of the risk
Reduce or eliminate the risk
Determine costs?

Question 7

Who do all NHS trusts report incidents to?

Answer 7

NRLS via local reporting systems