Adverse Events Reporting Protocol.

Purpose: This protocol provides hospital staff with a procedure, timelines, and a structured approach for the reporting of all serious incidents.

Target: All staff members.

Author: Quality Health and Safety Department

Introduction

For this protocol, adverse events will be defined as situations in which the consequences to patients, families and carers, staff or the organization is significant or the potential for learning is so great that a heightened response is justified. These incidents include all category 4 and 5 mortalities, near misses, never events or any untoward harm occurring to the patient during medical care. Some examples include care on the wrong patient such as wrong drug administered, wrong surgery, serious malfunction in any support services such as oxygen or vacuum, patient fall resulting into serious injury, pressure ulcers, injury to patient or staff member following assault (physical or sexual) and many others. It also includes areas where the clinical team feels there might be potential for litigation.

It applies to all members of the hospital-both clinical and non clinical- all areas where care is provided to patients and any staff member is allowed to raise a concern. It describes the procedure and timelines to be followed in the event a serious incident has occurred, including the time frame between occurrence of such an incident and official reporting, reporting requirements, where such reports are to be sent and what the report should contain.

This protocol highlights the importance of creating a culture of safety that focuses attention on the identification and implementation of improvements that reduce the likelihood of recurrence of serious incidents. Its purpose is to ensure that serious incidents are identified correctly, audited thoroughly, and most importantly, learned from to reduce the likelihood of similar incidents happening again.

Reporting Procedure

In the event of a serious incident as defined above, the primary care giving team shall notify the Manager, Quality Health and Safety of such occurrence.

Notification shall be done by the Nursing HOD
Notification shall include date, time and venue of a comprehensive audit following the serious incident.
Notification shall also be made to other teams involved in care other than the primary team detailing date, time, and venue of the audit.

The primary team shall meet to have a comprehensive audit of the case not more than 4 days after occurrence.

The audit shall include a full factual account of the incident including a timeline/chronology of key events.
Where care involved a multi-disciplinary team, all teams shall be present for the audit.
The most senior team member of the primary team and other teams involved in care shall be expected to be present for the audit.
The audit shall capture full facts and sequence of events that led to the serious incident including the following: a. Patient details including patient name, age, gender, location of occurrence of serious incident, and what happened.
b. Level of harm/seriousness c. What went well and identify examples of good practice
d. What went wrong and what can be learnt from the incident e. Root cause of the incident and contributory factors f. Actions required to prevent recurrence of such incidents and persons responsible for implementing change. g. Time frame within which to follow up on implementation of said changes.

After completion of the comprehensive audit, a copy of the audit report including findings and recommendations shall be sent to the manager, Quality Health and Safety at qualityhsmgr@kijabehospital.org and the Director of Clinical Services at dirclin@kijabehospital.org
The quality and safety office will be responsible to

Compile and file all incidents at a central place
Track implementation of proposed recommendations
Give a report to the Executive Director, SMT, Medical Quality and Training Committee of the Board and Divisions meetings at agreed on intervals.