HOSPITAL POLICY AND INFORMATION MANUAL INCIDENT POLICY, Page 1 of 16

Date Issued: Date Last Revised: Next Review Date: Approved By: 9/98 10/13 10/15 Policy Committee

Policy Applies To All Mercy Hospital Staff Credentialed Medical Specialists and Allied Health Personnel are required to indicate understanding of the incident policy via the credentialing process and adherence to the Mercy By-Laws Board of Directors are required to analyse summarised incident information via Quality and Risk Advisory Committee and Board of Directors meetings.

Related Standards Health & Disability Sector Standard 2.4 Criteria 2.4.1, 2.4.2, 2.4.3, 2.4.4 EQuIP Standard 2.1 Criterion 2.1.3. Rationale Mercy Hospital manages health care incidents to ensure improvements to the systems of care. Mercy Hospital Incident policy is based on the following principles; Transparency and open disclosure Openness of incident reporting Systems focus not individuals Emphasis on learning and continuous improvement Obligation to act Accountability Fairness Appropriate prioritisation of action The aim of this process is to provide a safe environment for patients, staff, visitors, and all others involved in the provision of services at Mercy Hospital. Definitions Incident: An incident is an event or circumstance which could have, or did result in unintended or unnecessary harm to a person, and or a loss or damage to property. Near Miss: is an event that could have had adverse consequences but did not and is indistinguishable from an actual incident in all but outcome. A near miss may occur when a chain of events is interrupted. Serious Harm: (from Schedule 1 of the Health and Safety in Employment Act 1992). See appendix 2

HOSPITAL POLICY AND INFORMATION MANUAL INCIDENT POLICY, Page 2 of 16

Date Issued: Date Last Revised: Next Review Date: Approved By: 9/98 10/13 10/15 Policy Committee

Adverse event-is a health care event causing patient harm that is not related to the natural course of the patients illness or underlying condition (likely SAC 3 or 4) Serious adverse event requires significant additional treatment but is not life threatening and has not resulted in a major loss of function (likely SAC 1&2) Sentinel adverse event is life threatening, or has led to an unanticipated death or a major loss of function (likely SAC score 1&2) Open Disclosure :( OD) is a transparent approach to responding to an incident that places the consumer/staff member/contractor central to the response. This includes the process of open discussion and ongoing communication. An OD approach also includes support for staff and the development of an OD culture where staff are confident that the associated investigations will have a quality improvement rather than a punitive focus. Root Cause Analysis (RCA) is defined as a systematic process whereby the factors which contribute to an incident are identified by reconstructing the sequence of events and repeatedly asking why until the underlying root causes (contributing factor/hazards) have been made clear. Severity Assessment Code (SAC) is a numerical score given to an incident, based on the consequence or outcome of the incident and the likelihood that it will recur. A matrix is used to stratify the actual and/or potential risk associated with the incident Objectives 1. To ensure that there is immediate management of an incident when required and that every incident is appropriately prioritised ,investigated and managed 2. To ensure that the appropriate process is undertaken for the investigation of all incidents, near miss and adverse events. To ensure transparency of approach when responding to an incident that places the consumer /staff member central to the response. This includes the process of open discussion and ongoing communication with the consumer/staff member and their support person(s) To create a just culture where it is safe to report incidents and where a systems approach to incidents and investigation is used.

3.

4.

HOSPITAL POLICY AND INFORMATION MANUAL INCIDENT POLICY, Page 3 of 16

Date Issued: Date Last Revised: Next Review Date: Approved By: 9/98 10/13 10/15 Policy Committee

5.

To identify opportunities to improve the quality of care through ensuring the Incident system is a planned and co-ordinated process that links to the quality and risk management system. To minimise risk and prevent future incidents through development of appropriate action plans, recommendations and review. To meet statutory and/or regulatory requirements through informing staff of their responsibilities in relation to essential notification reporting and ensuring the correct authority is notified in an accurate and timely manner by the organisation. Ensure integration of complaints, patient feedback, staff feedback, credentialed specialists and allied health personnel feedback where appropriate.

6.

7.

8.

Implementation 1. Education All staff will be educated on the Incident policy and process, the need for accurate and specific documentation of incidents, the appropriate use of the incident form and the open disclosure process. This is addressed during annual staff training, orientation and at specifically targeted staff forums. Education is provided to new staff at time of orientation on the prevention and minimisation of risk and is co-ordinated by the Occupational Health and Infection and Prevention Control Nurse and Quality Co-ordinator. All credentialed specialists and allied health staff are instructed in Mercy Hospital's Incident Policy on commencement of work at Mercy. Ongoing updates are provided via Medical Advisory and E-mail communication. Contractors are notified via the Information Handbook for Contractors which is issued at the commencement of the contract and thereafter at contract renewal. Core members of staff are appropriately trained in incident investigation and root cause analysis via HQSC on line resources

HOSPITAL POLICY AND INFORMATION MANUAL INCIDENT POLICY, Page 4 of 16

Date Issued: Date Last Revised: Next Review Date: Approved By: 9/98 10/13 10/15 Policy Committee

2.

Reporting Reporting of incidents is an integral part of Mercy Hospitals legal responsibilities and quality programmes. This includes but is not limited to the following: Severity assessment code (SAC) 1 will be notified to the Chief Executive Officer who will escalate to the Board of Directors as appropriate. This will be done within one working day of the incident occurring. Reporting to designated agencies will occur promptly as defined by statutory/regulatory requirements. A monthly report of all registered events will be tabled at the Quality and Risk Advisory Meeting. These will have been risk rated and categorised to show trends. This report will be collated monthly and placed on Theatre and Lower Ground Floor noticeboards. Staff incident reports will be also be reported at the monthly Health and Safety and Infection Prevention and Control representatives meetings.

3.

Evaluation All incidents are risk rated using the Severity Assessment Code(SAC) All incidents are reviewed and where appropriate, an action plan is developed for change of process, practice, policy and or education. All SAC 1 incidents have a full investigation that includes root cause analysis and development of recommendations for change of process, practice, policy and education as relevant All SAC 2 incidents are investigated using appropriate tools. A specific, identified person is designated as responsible for ensuring the recommendations are carried out and efficacy of any change is evaluated. All SAC 1 & 2 incidents are reviewed with a view to escalating to the risk register.

HOSPITAL POLICY AND INFORMATION MANUAL INCIDENT POLICY, Page 5 of 16

Date Issued: Date Last Revised: Next Review Date: Approved By: 9/98 10/13 10/15 Policy Committee

All SAC 1 & 2 incidents are tabled at the monthly Quality and Risk Advisory Committee meetings. Where relevant, incidents will be forwarded to the Surgical Audit Group for further review and comment. All incidents which fulfil the mandatory reporting criteria where relevant will be reported to eg: MBIE, HSQC and MOH reporting Compliance for the above points will be monitored via audit. Support for consumers, patients and staff involved in incidents is evaluated via patient questionnaire feedback, complaints process and feedback, staff survey Transparency and open disclosure is evident via clinical records, incident forms and audit

Associated Legislation Health Act 1956 reprint 2010 Coroners Act 2006 Births, Deaths & Marriages and Relationships Registration Act 1995 Health and Safety in Employment Act, 1992 Health & Disability Services ( Safety) Act 2001 New Zealand Public Health & Disability Act 2000 Health Practitioners Competence Assurance Act 2003 Chapman Tripp Mercy Hospital Legislative Compliance Programme Associated Documents Mercy Hospital Incident Form refer Appendix 3 Mercy Hospital By-Laws for Credentialed Specialists Hazard Identification Policy Hospital Policy and Information Manual Section 7, In-house Rules, Human Resources Manual Terms of Reference Quality and Risk Committee Hospital Policy and Information Manual Terms of Reference Health and Safety and Infection Prevention and Control Representatives Committee, Hospital Policy and Information Manual Information Handbook for Contractors New Zealand Health and Disability Services - National Reportable Events Policy 2012

HOSPITAL POLICY AND INFORMATION MANUAL INCIDENT POLICY, Page 6 of 16

Date Issued: Date Last Revised: Next Review Date: Approved By: 9/98 10/13 10/15 Policy Committee

Appendices 1. Severity assessment code 2. Serious harm definition 3. Incident Report form

INCIDENT MANAGEMENT PROCESS

Incident occurs Immediate action taken

Notify line manager

If staff incident notify H&S/ICP Nurse

Line Manager commences investigation

Allocate SAC score

O N G O I N G
SAC 1 or 2

SAC 3 or 4

Action by person responsible Investigation/review undertaken

1. RCA investigation initiated (Following actions for SAC1, where appropriate for SAC2) 2. RCA final documentation collated into Incident form 3. Feedback to consumer, family and staff 4. Appropriate notifications as per Mandated reporting table 1

F E E D B A C K

Action plan developed Corrective actions implemented

Actions and Outcomes tracked on Incident Database

SAC 1 & 2 Report monthly to Quality and Risk Committee

Incident management Process 1. Identification 2. Immediate action 3. Notification 4. Prioritisation

INCIDENT MANAGEMENT PROCESS 5. Investigation 6. Classification 7. Analysis 8. Improvement Action 9. Feedback 10. Evaluation 1. Identification Incidents Adverse events Near miss events: identification and reporting of all accidents or near-miss incidents which lead to, or could have led to harm to determine if they were caused by a significant hazard. ACC treatment injury Complaints process (in this case the person dealing with a complaint must bring the complaint to the attention of the relevant member of the Executive and it is dealt with as both a complaint and an incident), Patient feedback via patient questionnaire Staff Feedback Consultant/Allied health feedback Audits Staff meetings,

Team discussion

Once an incident has been identified by a person, the first page of the Mercy Hospital Incident Form must be completed and sent to the appropriate line Manager. 2. Immediate Action Immediate action may need to be taken to mitigate the harmful consequences of the incident. This includes appropriate clinical care and support for the person(s) involved. 3. Notification required for all Incidents, Near Miss, and Adverse events Incident notification- by the notifier (Staff) In the event of a serious harm incident to a staff member or contractor, where possible the scene of the incident should be secured by the person in charge of the area. The appropriate Executive member or Executive on call must be notified so that the Ministry of Business, Innovation & Employment can be notified accordingly. (MBIE can be notified on line http://www.business.govt.nz/healthandsafetygroup/notificationsforms/accident-serious-harm) (see appendix 2)

INCIDENT MANAGEMENT PROCESS For serious harm incidents that involve patients the above notification also applies. Incident notification - by the notifier (Patient) Notification of an incident may be made on the Mercy Hospital complaint form and given to the appropriate Line Manager or be sent into Reception Incident notification by the Manager Managers who receive an incident form must; undertake an initial assessment of the severity of the incident using the SAC matrix (appendix A) take immediate action if appropriate escalate as required The second and third pages of the incident form need to be completed where possible The Incident form is then placed in appropriate black Incident box (whether completed or not) Quality Co-ordinator or designate collects incident forms from box (daily check) and inputs to database The Incident form is then placed in one of the black Incident boxes appropriate to the relevant department (whether completed or not) Manager gives incident a SAC score if this has not already been completed, and checks all corrective actions are complete DoCS signs off and gives back to QC (to complete actions on database) Copy of form given to person initiating report. Informing and involving the Consumer Transparency and open disclosure is a right under the Code of Health & Disability Services Consumers Rights 1996. A consumer will be informed about any adverse event. An error that affected their care but does not appear to have caused harm may also need to be disclosed to a consumer This disclosure will include acknowledgment of the incident, an explanation of what happened, how it happened and where appropriate what actions have been taken. Do not however pre-empt any investigation and jump to conclusions about cause. A disclosure should also include a sincere apology. The consumer should be given details about the local H&D consumer advocate as well as options for making a complaint (available at all Reception areas) Where appropriate assure consumers that they may be entitled to compensation under ACC. (ACC Treatment injury forms are kept in the Director of Clinical Services office)

INCIDENT MANAGEMENT PROCESS The health professional with overall responsibility for the consumers care should usually disclose the incident. The disclosure should take place in a private room as soon as is practicable following the incident, taking into account whether the consumer is medically stable enough to understand information. A disclosure should generally be made to the individual consumer and any support people the consumer wishes present. In circumstances where discussion with the consumer is not possible or appropriate, his or her, next of kin, designated contact person or representative should be informed. Documentation of the conversation and any subsequent action must be recorded in the consumers notes It is important to note that open disclosure is not a single conversation, but a process of ongoing communication Appropriate consideration must be given to the consumers cultural customs as well as any special needs the patient may have. A single point of contact person must be identified for the Consumer in order to ensure consistency of approach. Support for the staff member undertaking the disclosure is integral to ensuring that open disclosure becomes the norm: a. Deciding who should attend (a senior colleague accompanying a staff member for the disclosure may be helpful) b. Good pre planning in terms of content c. Anticipating patient and family needs d. Appropriate education on disclosure for staff Additional support for the health professional or staff member can be accessed through Staff assistance programme (SAP), appropriate Line manager or member of the Executive.

Incident Notification to Executive All SAC 1 incidents must be reported to the appropriate Executive member or Executive on call as soon as possible Notification to Central Agency SAC 1 and SAC 2 incidents are required to be reported to the Health Safety Quality Commission (this being undertaken on a voluntary basis and is not a mandatory requirement for New Zealand Private Hospitals.

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INCIDENT MANAGEMENT PROCESS Mandated reporting Table 1

Event related to Serious harm to employees/patients/contractors Significant Clinical Events Misadministration of radioactive materials Electricity related incidents causing injury, death or electronically initiated fires Gas accidents Serious issues involving quality of medicines Medical devices that caused or could have caused injury to the patient or device user Explosive events Serious harm to patients Deaths Deaths Public health emergencies Communicable diseases Treatment Injury Nursing Competency/Health issues

Reported to Ministry of Business, Innovation and Employment Health Quality & Safety Commission National Radiation Laboratory Energy Safety Service, Ministry of Consumer Affairs Energy Safety Service, Ministry of Consumer Affairs Compliance Team at Medsafe, Ministry of Health Compliance Team at Medsafe, Ministry of Health Dangerous Goods Inspector Ministry of Health; Health Quality Safety Commission Coroner Ministry of Health Ministry of Health Ministry of Health ACC Nursing Council of New Zealand

4. Prioritisation All incidents must be prioritised to ensure that the appropriate action is taken on each incident. This is done using SAC scoring ( Appendix 1). The score must be ascertained by rating the consequence of the incident and its likelihood of recurrence. Determine the consequence of the incident using the definitions provided Determine the likelihood of recurrence Allocate a SAC score Determine the appropriate action using the table provided 5. Investigation All incidents notified must have some form of review or investigation.

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INCIDENT MANAGEMENT PROCESS SAC1 must be investigated by staff trained in Root cause analysis methods using the New Zealand Incident Management System tool. The RCA team must not include the consumer or health professional(s) involved in the incident. Key points of concern identified by the consumer must be recorded. The report must include an action plan that includes recommendations for change of system, process or practice as appropriate. A SAC2 incident must have a detailed investigation but it is not mandatory that it goes through a RCA process. All other measures as above are also appropriate to SAC2. All investigations will sit in a central repository. SAC3 & SAC4 The investigation of these incidents will be undertaken at a ward and department level by the appropriate Line Manager/Team Leader/Clinical Coordinator Following review of individual incident forms, it may be more efficient to investigate common incident types and develop an action plan. This level of review might identify; System issues that need to be addressed Appropriate quality improvement action to prevent recurrence where possible Investigation must be completed within 28 calendar days Monthly trending may also identify and prioritise issues requiring improvement 6. Classification All incidents must be classified into categories to identify trends, hazards and develop strategies to decrease harm. 7. Analysis All patient incidents will be classified, trended according to this classification and presented to the Quality and Risk Committee for further review on a monthly basis. All Patient incidents will be coordinated by the Quality Coordinator and staff incidents by the Occupational Health and Infection and Prevention Control Nurse. 8. Improvement Action The implementation of recommendations from the investigation must include; Responsibility for accepting the recommendations for SAC1 & SAC2 which sits with the Quality and Risk Committee Resource approval for these recommendations sits with the Executive

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INCIDENT MANAGEMENT PROCESS Responsibility for actioning the recommendations for SAC3 & SAC 4 sits with the appropriate line Manager/Team Leader/Clinical Coordinator A timeframe must be nominated in all action plans Those responsible for actions must be identified and held accountable for the action

Those responsible for the action must report on their implementation and must put in place a mechanism for evaluation of the action at a date no later than 6 months following implementation 9. Feedback on the investigation, recommendations and implementation will be shared with those involved in the original incident, consumer, staff, Credentialed Specialists and Allied health personnel. The level of the incident (SAC score) will dictate who gives the feedback. SAC 3 & 4 will be notified by one on one feedback, staff forums SAC 1&2 feedback will be provided by those involved in the incident investigation. 10. Evaluation Evaluation of effectiveness of measures implemented will be done via; Audit Incident trends Non recurrence of incidents/review of further incidents Staff/patient feedback All paperwork relating to; staff incidents must be sent to the Occupational Health and Infection Prevention and Control Nurse patient incidents must be sent to the Quality Coordinator

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APPENDIX 1

Consequence Table

Rate all adverse events on ACTUAL OUTCOME Rate all near misses on the most likely potential outcome
Incidents with a high POTENTIAL SAC rating can be notified to the Central Repository (HQSC) via REB at the discretion of the organisation Severe Major Moderate Minor Minimal

Generic Consequences (applicable to all health and disability services)

Death or permanent severe loss of function that is related to the process of health care and differs from the expected outcome of that care. Permanent major or temporary severe loss of function that is related to the process of health care and differs from the expected outcome of that care. Permanent moderate or temporary major loss of function that is related to the process of health care and differs from the expected outcome of that care. Permanent minor or temporary moderate loss of function that is related to the process of health care and differs from the expected outcome of that care. Temporary minor loss of function.

Specific Incidents/Consequences
Wrong consumer or wrong procedure with risk of or actual severe harm Suicide as inpatient Blood component given to wrong consumer Retained item with delayed removal Child/infant abduction or discharge to the wrong family Failure of essential service with risk of severe consumer consequences Wrong consumer or wrong procedure with risk of or actual major harm Retained item with immediate removal Misadministration of radioactive materials Unanticipated cardio-pulmonary resuscitation resulting from the process of health care Community suicide by current mental health consumer within 28 days of contact with service Missing person with a risk of serious harm to self or others Wrong consumer or wrong procedure with risk of or actual moderate harm Fall resulting in fracture Wrong consumer or wrong procedure with risk of or actual minor harm Additional monitoring, investigations or minor interventions as a result of the incident Medication error with no harm

Any of the following as a result of the incident: Transfer to higher level of care, including hospitalisation Increased length of stay (>one day) Surgical or other significant intervention required

Associated Documents: Incident policy and New Zealand Incident Management System tool

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APPENDIX 1 Likelihood Table

CONSEQUENCE
LIKELIHOOD CATEGORY Almost Certain DEFINITION Severe
Almost certain to occur at least once in next three months Will probably occur at least once in the next four-12 months Is expected to occur within the next one to two years Event may occur at some time in the next two to five years Unlikely to recur may occur only in exceptional circumstances ie >five years

Major

Moderate

Minor

Minimal

1 1 1 1 1

1 1 2 2 2 Review Process

2 2 2 3 3

3 3 3 4 4

4 4 4 4 4

Likely

Moderate

Unlikely

Rare

SAC 1 SAC 2 SAC 3 SAC 4

Complete REB Part 1 and send to HQSC within 15WD Formal review using RCA methodology / London Protocol Complete REB Part 2 and send to HQSC within 70WD

Review of incident within 30WD May complete REB Part 1 and Part 2 and send to HQSC if considered relevant eg. Health sector issue or learning

Associated Documents: Incident policy and New Zealand Incident Management System tool

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APPENDIX 2

Below is the definition of Serious Harm from Schedule 1 of the Health and Safety in Employment Act 1992 Serious harm means death, or harm of a kind or description declared by the GovernorGeneral by Order in Council to be serious for the purposes of the Act; and 'seriously harmed' has a corresponding meaning. Until such an Order in Council is made, the following types of harm are defined in Schedule 1 as 'serious harm' for the purposes of the Act: 1. Any of the following conditions that amounts to or results in permanent loss of bodily function, or temporary severe loss of bodily function: respiratory disease, noise-induced hearing loss, neurological disease, cancer, dermatological disease, communicable disease, musculoskeletal disease, illness caused by exposure to infected material, decompression sickness, poisoning, vision impairment, chemical or hot-metal burn of eye, penetrating wound of eye, bone fracture, laceration, crushing. 2. Amputation of body part. 3. Burns requiring referral to a specialist registered medical practitioner or specialist outpatient clinic. 4. Loss of consciousness from lack of oxygen. 5. Loss of consciousness, or acute illness requiring treatment by a registered medical practitioner, from absorption, inhalation or ingestion of any substance. 6. Any harm that causes the person harmed to be hospitalised for a period of 48 hours or more commencing within seven days of the harm's occurrence. http://www.business.govt.nz/healthandsafetygroup/information-guidance/legalframework-for-ensuring-a-safe-and-healthy-workplace/hse-act-1992/serious-harmdefinition

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