Speaker 1: Welcome to this short film about incident reporting. We are going to be looking at what everyone in the trust needs to do whenever an accident or incident happens which causes

Speaker 2: harm or injury. The trust takes patient safety very seriously. Most of the time everything goes to plan but it is inevitable that sometimes incidents occur which cause harm to patients. We have clear procedures to make sure everyone in our trust acts in the right way to meet our personal, professional and statutory responsibilities. First step everyone must take is always to report an incident. This matters not just when what has happened is serious, it matters also where less serious harm might have occurred.

Speaker 1: So let's start by being clear about what is meant by an incident. The definition the trust uses is an unintended event or circumstance that could have resulted or did result in unnecessary damage, loss or harm such as physical or mental injury. This covers harm to a patient or to a contractor. Incidents also can happen involving volunteers, visitors and members of the public. All are covered by one procedure and by one reporting system in this trust. So we need to report incidents where patient safety is involved. But don't forget other incidents include non-clinical issues which are just as important, such as health and safety anywhere in the trust, any fraud and theft from the trust, misuse of information and data in any way, not just in relation to patients, not forgetting security and damage to property. But what types of incidents are

Speaker 3: we talking about? Fortunately when incidents occur they do not always have serious consequences, but they should all be reported. Severe harm caused by incidents and catastrophic consequences such as actual death are very rare. Most incidents have actually involved no material harm at all or are about near misses. These incidents still need to be reported. Our trust, like all NHS organisations, has clear and comprehensive procedures to ensure the four main types of incident are reported properly and the right level of action is taken to match the severity of what has happened. In the end we must improve the way we work by learning from each incident, however small.

Speaker 1: The four types of events are Incidents Critical incidents Serious incidents We shall now deal with each in turn. Here is the flowchart showing what needs to happen for all incidents. You can see that once the incident occurs it has to be reported to the line manager who is required to make a decision. If it is a serious incident then it follows a different path, we'll come to that in a minute. If it is not serious another decision has to be made about what to review and how to investigate the incident in a way that fits the severity of what has happened. If it is a critical incident there are clear timescales for formal investigation and action. If it is more routine, a non-serious incident, then just an action plan may be needed. Everything is recorded on Ulysses, the Trust's risk management system. Anyone can report an incident through the intranet. It is everyone's responsibility to know how to do this. You will receive a copy of this simple electronic incident reporting guide as part of the training. There is also training available on the Trust's 5x5 risk scoring system. All we need to know here is that simple scoring system allows the severity of the risk and the likelihood of the risk reoccurring to be assessed straight away. It is more straightforward than it looks. This helps decide if the incident is serious enough to be handled as a real priority.

Speaker 4: Serious incidents are not just about unexpected or avoidable deaths and suicide. Serious incidents often referred to as SIs also include any unexpected or avoidable injury where further treatment is needed by a healthcare professional in order to prevent death or harm. In recent years, sadly, we have all heard about examples of sexual, physical and psychological abuse which has happened in many organisations. So remember, all forms of abuse, exploitation, discrimination and neglect also must be reported immediately as serious incidents.

Speaker 1: So serious incidents are taken very seriously. They must be reported immediately so they can be fast-tracked 24 hours a day on a serious incident form. These escalate the issue to the Critical Incident Team and the Executive Directors of the Trust. Within two days, senior staff have to complete a thorough root cause analysis of what happened, gather evidence and take necessary action. Other agencies and professionals may be involved. So serious incidents are a big deal and will be reported externally to the Trust Development Authority, Clinical Commissioning Groups, the Care Quality Commission and where necessary the police and other agencies. The reputation of the Trust will be on the line. It will be judged by how well it handles each case. But there is also much that can be learnt and shared inside the Trust. Finally, there are what are called Never Events. Never Events are also serious incidents. But they need a special mention on their own. Never Events are incidents which everyone recognises are completely preventable if only widely available measures had been followed. Measures which were already known could have prevented the event happening. You can see from some of the examples here why they are called Never Events. They are listed on the NHS England website every year. They remind us all of the value of reporting incidents so we can learn and improve the safety of ourselves and others.

Speaker 2: Every serious incident tells us a lot about how we can improve. This is the positive side of serious incidents. The value of root cause analysis and the evidence we have worked through cannot be underestimated. Selected serious incidents are discussed at our weekly Patient Safety Summit so we can draw out lessons and change the way we work. This way we can turn events which have involved harm and damage into a real spur to action to create positive

Speaker 1: change and improve practice. It pays to take time, to reflect and to learn. Reporting incidents is not something which stands on its own. It is part of the way the Trust manages risk, meets the duty of candour, handles complaints and ensures it provides the highest standards of patient safety and care. Reporting needs to be part of this culture if we are to increase public confidence in what we do. The training that goes with this film covers the step-by-step incident reporting procedures in the Trust in more detail. Thank you for your attention. For more information visit www.fema.gov