Inter-organisational incident and near-miss reporting is a mechanism for identifying potential or actual problems or incidents that have occurred in relation to children’s palliative care in the Northwest.
Identifying when things have not gone as expected and near misses when something nearly went wrong is a really important way of identifying risks to patients and their families. If we identify these actual or potential risks we can look at ways of preventing problems happen in future. Failure to report or act upon identified risks subjects patients and professionals to unnecessary risk. As a Network we work to support children with palliative care needs and their families. Often this involves partnership working between different teams and services. Often the biggest risks to safe effective patient care are present when we are working across team or organisational boundaries. It is therefore essential that we have a mechanism for identifying these risks and when problems arise so that we can act to minimise or actively manage the risk.
No patient identifiable information will be shared between organisations other than if it is necessary to identify the patient across more than one organisation in order to investigate the incident or take appropriate action to prevent or reduce the likelihood of recurrence
Yes. In line with Being Open policies and Duty of Candour the incident should be reported to the parent or guardian and if relevant to the patient. However if the incident is only recognised outside the team or service where the issue originated it may be more appropriate to contact the team or service where the issue originated and advise them to do this.
No. Inter- Organisational Incident and Near Miss reporting is undertaken completely independently of any disciplinary action. The principle is for a no blame culture where we are looking to identify the combination of circumstances that lead to an incident in order to prevent it happening again rather than automatically blaming someone because they made a mistake.
Yes. Sometimes an incident or near miss is only recognised outside the team or service where the issue originated. For example if an Advance Care Plan was ambiguous or contradictory that may not be spotted until the ambulance crew was called to the child at home. Please report all relevant incidents. If the reporting details are completed fully we will be able to identify instances when we have received more than one report relating to the same incident.
Serious Incidents (Serious Untoward Incidents, SUIs) include acts or omissions in care that result in; unexpected or avoidable death, unexpected or avoidable injury resulting in serious harm - including those where the injury required treatment to prevent death or serious harm, abuse, Never Events, incidents that prevent (or threaten to prevent) an organisation's ability to continue to deliver an acceptable quality of healthcare services and incidents that cause widespread public concern resulting in a loss of confidence in healthcare services. If a Serious Incident occurs it is essential that it is reported, in the first instance, through the normal processes in your own organisation. A Serious Incident will trigger a Root Cause Investigation. The Network should be notified of the Serious Incident but no further actions will be taken by the Network until the Root Cause Investigation has been completed and the Network has received the final report.
Yes, the processes for Inter- Organisational Incident and Near Miss reporting have been set up by the Northwest Children's Palliative Care Network in accordance with the clinical governance and risk management policies of the organisations that are represented at the Network.