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Quality & Safety - Safety Incident Management Policy (2014)

A column by Maureen Flynn

This month we focus on the HSE’s newly- published Safety Incident Management Policy. Published in May 2014, in a single document, this provides the guidelines and procedure to be followed when incidents are identified. A programme of training on the new policy is currently underway.

The Safety Incident Management Policy (2014) brings together a number of separate documents into one consolidated policy which replaces the following HSE documents:

  • Risk and Incident Escalation Procedure (2010)
  • Risk and Incident Escalation Form (2010)
  • Toolkit of Documentation to Support Incident Management in the HSE (2009)
  • Serious Incident Management Policy (2008)
  • Serious Incident Sign-off Form (2008)
  • Incident Management Policy and Procedure (2008).

The aim is to have the information from the above in a single updated document that HSE managers and employees will find easier to read and use.

Overview of the policy
The updated policy includes information on all the basic elements of incident management. It also includes additional information such as the importance of applying the HSE Open Disclosure Guidelines (2013) when an incident is identified. It has new information about what incidents need to be reported to what agencies and how. It contains new information on conducting assessments to determine the type of investigation required, including guidance for decision making about when:

  • No further investigation is required
  • A systems analysis of an incident is required
  • A look-back review is required
  • An aggregate analysis of incidents is required.

The updated policy has a new focus on the importance of convening a safety incident management team to manage incidents. It includes a suite of documentation to support safety incident management teams including:

  • Terms of reference for safety incident management teams
  • Roles and responsibilities of individual members
  • Template meeting agenda.

There is a section on consent for access to health records for conducting safety incident investigations, including a sample consent form and accompanying patient information pamphlet.

Role of the safety incident management team
  • Manage immediate safety issues
  • Care for those harmed/affected
  • Ensure contingency planning for service continuity when needed
  • Ensure appropriate investigation of incidents in line with HSE policies
  • Facilitate sourcing of external independent experts to investigation teams if investigators deem this necessary
  • Manage communications about the incident with service users, employees and other stakeholders
  • Inform recommendations arising out of investigations
  • Arrange for expeditious implementation of recommendations

Other new information covers mechanisms for communicating and addressing immediate safety concerns that arise following the identification of an incident; how to proceed with a safety incident investigation when other investigations are ongoing or anticipated; circulation of completed investigation reports; and national learning in response to incident reporting, investigation and analysis.

A modified incident decision tree is included in the appendices to assist managers with decision-making during incident management and there is new guidance on supports available for employees and supports to be provided to service users when incidents occur.

The updated policy gives guidance on the management and reporting of ‘serious reportable events’ and includes new guidelines for external independent experts giving input to HSE investigations.

We hope this updated policy will help us all to improve how we respond and learn from incidents, and that this will result in concrete safety improvements for our service users, our employees and the public.

Training in incident management
The national incident management team is collaborating with the leads for quality and patient safety in the new divisions to deliver incident management and investigation training to support the implementation of this updated policy. Training details are available on the QPSD website. This training awards Nursing and Midwifery Board continuing education units (CEUs) to nursing/midwifery professionals and continuing professional development (CPD) credits to medical professionals. Further details from the course co-ordinator: Geraldine Donaghy, Email: geraldine.donaghy1@hse.ie, Tel: 01 6352099.

Opportunity to get involved
It is important for each nurse and midwife to be aware of the updated policy. At your next ward, department or team meeting, you could include a discussion on the updated policy. The policy is available to download from the QPSD incident management section of the HSE website at: http://www.hse.ie/eng/about/Who/qualityandpatientsafety/incidentrisk/Riskmanagement/ SafetyIncidentMgtPolicy2014.pdf

Maureen Flynn is the Director of Nursing (national lead for quality and safety governance development) at the Office of the Nursing and Midwifery Services Director, Quality and Patient Safety Division, HSE

Particular thanks to Cora McCaughan and Deirdre Coyne of the Quality and Patient Safety Division of the HSE for their assistance with this column

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