The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [119]
accident to member of staff, patient, visitor or other person
security incident
violence, aggression
ionizing radiation incident (non-clinical)
equipment (non-medical) incident
environmental incident, for example chemical spillage, flood, fire, waste disposal
food safety incident (NPSA 2009).
Non-clinical prevented incident
A situation in which an event or omission, or a sequence of events or omissions, fails to develop further, whether or not as the result of compensating action, thus preventing harm/injury.
Serious untoward incident
A serious untoward incident (SUI) is an accident or incident involving a patient, member of staff, visitor on NHS property, contractor or other person to whom the organization owes a duty of care, that causes actual serious injury or unexpected death.
SUIs may include:
permanent harm to one or more patients, staff, visitors or members of the public or where the outcome requires life-saving intervention or major surgical/medical intervention or will shorten life expectancy
unexpected death of a baby, child or young person
a scenario that prevents or threatens to prevent a provider organization’s ability to continue to deliver healthcare services, for example, actual or potential loss or damage to property, reputation or the environment
serious abuse or physical attack of a person on NHS property
an incident likely to attract adverse media coverage or public concern for the organization or the wider NHS (NPSA 2009).
Never events
Serious, largely preventable patient safety incidents that should not occur. The core sets of ‘never events’ are updated by the NPSA on an annual basis and currently include (NPSA 2009):
wrong site surgery
retained instrument post operation
wrong route administration of chemotherapy
misplaced nasogastric or orogastric tube not detected prior to use
inpatient suicide using non-collapsible rails (mental health)
escape from medium- or high-security mental health services
in-hospital maternal death from postpartum haemorrhage after elective caesarean section
intravenous administration of mis-selected concentrated potassium chloride.
Never events are immediately reportable to the NPSA and may affect healthcare organizations’ registration with the Care Quality Commission. Healthcare providers may also be subject to financial penalties if never events occur within their organization.
Evidence-based approaches
Raising the profile of risk management in the UK
Risk management and risk prevention have come to dominate the healthcare agenda in the UK (Southgate and Dauphinee 1998, Vincent 2006).
Across the world, several notable incidents involving one or more deaths have led to a refocusing of the safety culture (Alaszewski 2002, Flynn 2002). In the UK, the events that occurred at the Bristol Royal Infirmary were instrumental in the regulation of healthcare. Events such as those that happened at Bristol and more recently at the Mid-Staffordshire NHS Foundation Trust (Francis 2010) have highlighted key issues such as culture, leadership, lack of critical analysis, inward looking and in some cases lack of clinical ownership (Francis 2010, Heyman et al. 2010, Weick and Sutcliffe 2003). The Department of Health has drawn upon Bristol, Mid-Staffordshire and other evidence from major global incidents in medications and screening to support the urgency of improving risk management and the safety and consistency of healthcare treatments and outcomes (Heyman et al. 2010).
The Bristol Inquiry findings provided supporting arguments for reforms designed to develop a more systematic approach to setting, delivering and monitoring standards in healthcare (DH 1998).
Clear national standards for services and treatments, through National Service Frameworks (NSFs) and a new National Institute for Clinical Excellence (NICE).
Local delivery of high-quality healthcare, through clinical governance underpinned by modernized professional self-regulation and extended life-long learning.
Effective monitoring