Significant Event and Incident Reporting Policy

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Providing safe, effective, high-quality patient care is the aim of all staff at Yalding Surgery. Given the complexity of primary care and the associated pressures resulting in increased clinical and administrative workloads, it is inevitable that significant events (SE), patient safety incidents (PSI) and other incidents may occur.

Clinicians need to review and record significant events for audit and revalidation purposes, practice managers need to report these for governance purposes and all staff need to easily understand what/how/why and when to report incidents.

This policy illustrates the organisation’s commitment to the safety of the patient population. By promoting a learning culture, staff are encouraged to report SE, PSIs and incidents that will foster learning and help to prevent the recurrence of similar incidents in the future.

It is the responsibility of all staff to ensure that they recognise, respond to and take the necessary actions regarding SE, PSIs and incidents. Staff must operate in an open and transparent manner, acknowledging that mistakes happen and take the subsequent necessary actions to report all incidents, thereby further reducing the risk of recurrence and ensuring that a high level of patient care is consistently delivered. Furthermore, staff are required to share best practice as SE, PSIs and incidents can arise through positive actions.

Significant event analysis (SEA herein) at Yalding Surgery is used to identify both good and poor practice. However, the overall aim of the process is to enable reflection and learning thereby enhancing the level of service offered to the patient population. SEA at Yalding Surgery involves all members of the multidisciplinary team (MDT). Staff must acknowledge that SEs are centred on whole team learning and are not used to direct blame.

The aims of completing SEAs are to:

• Identify events in individual cases that have been critical and to improve the quality of patient care from the lessons learned
• Instigate a culture of openness and reflective learning, not individual blame or selfcriticism
• Enable team building and support following stressful episodes
• Enable the identification of good as well as suboptimal practice
• Be a useful tool for team and individual continuing professional development, identifying group and individual learning needs
• Share learning between teams within the NHS where adverse events occur at the ‘overlap’ or in shared domains of clinical responsibility (such as ‘out of hours’, discharge problems, etc.)

Following any incident or event, part of the management response will be to instigate an investigation that includes an audit. The purpose of having an audit is to:

• Identify and highlight evidence-based practice
• Identify areas for improvement and enhance patient safety
• Provide data that can be used to review the effectiveness of service delivery
• Enhance multidisciplinary team communication
• Improve cross-functional working within the practice

If you have any further concerns or questions please contact the practice to disucss.