Patient Safety Incident Response Policy
Helen Rollason Cancer Charity take patient (client) safety very seriously. Our Patient Safety Incident Response Policy supports the requirements of the Patient Safety Incident Response Framework (PSIRF) and sets out HRCC’s approach to developing and maintaining effective systems and processes, for responding to patient safety incidents and issues for the purpose of learning and improving patient safety.
1. Policy Statement
This policy supports the requirements of the Patient Safety Incident Response Framework (PSIRF) and sets out Helen Rollason Cancer Charity’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents and issues for the purpose of learning and improving patient safety.
The PSIRF is a contractual requirement under the NHS Standard Contract and as such is mandatory for services provided under this contract.
The PSIRF advocates a co-ordinated and data-driven response to patient safety incidents. It embeds patient safety incident response within a wider system of improvement and prompts a significant cultural shift towards systematic patient safety management.
This policy supports development and maintenance of an effective patient safety incident response system that integrates the four key aims of the PSIRF:
- compassionate engagement and involvement of those affected by patient safety incidents
- application of a range of system-based approaches to learning from patient safety incidents
- considered and proportionate responses to patient safety incidents and safety issues
- supportive oversight focused on strengthening response system functioning and improvement.
2. Policy Principles
This policy is specific to patient safety incident responses conducted solely for the purpose of learning and improvement across all NHS Standard Contracts held by Helen Rollason Cancer Charity.
Responses under this policy follow a systems-based approach. This recognises that patient safety is an emergent property of the healthcare system: that is, safety is provided by interactions between components and not from a single component. Responses do not take a ‘person-focused’ approach where the actions or inactions of people, or ‘human error’, are stated as the cause of an incident.
There is no remit to apportion blame or determine liability, preventability, or cause of death in a response conducted for the purpose of learning and improvement. Other processes, such as claims handling, human resources investigations into employment concerns, professional standards investigations, coronial inquests and criminal investigations, exist for that purpose. The principle aims of each of these responses differ from those of a patient safety response and are outside the scope of this policy.
Information from a patient safety response process can be shared with those leading other types of responses, but other processes should not influence the remit of a patient safety incident response.
3. Our Patient Safety Culture
Helen Rollason Cancer Charity are committed to:
- Reporting any cross-organisational issues in line with local commissioner procedures.
- Fostering a just culture where our values of openness, honesty and non judgmental are key.
- Promoting the focus of incidents on the system of working in order to learn lessons.
- Having honest conversations with key partners and openly reporting on incidents as part of contract requirements.
4. System Partners in Patient Safety
HRCC will engage with key partners on a regular basis. We will ensure all serious incidents are communicated effectively but also ensure we jointly learn outcomes with our key partners from these incidents. HRCC will discuss with the appropriate safety lead within the local commissioner concerned of any serious incident.
5. Addressing Health Inequalities
HRCC review all data to help identify any disproportionate risk to patients. We will respond to any issues relating to health inequalities as part of the implementation of this policy. Our services, including our Support Groups, are open to everyone with a cancer diagnosis (and if appropriate their immediate family). The SSM continues to look for opportunities to work with hard-to-reach groups and is part of a Levelling Up Committee based in Essex.
All staff will be trained and aware of the HRCC PSIRF and Accident Policy when managing an incident and ensure that the client, and families and carers as appropriate, are kept at the centre of the process as appropriate. The Incident and Accident Policy clearly lays out the process in a step-by-step format and starts with ensuring the person who is involved is safe and receives the necessary attention needed.
Reporting mechanisms are in place at HRCC for responding to patient safety incidents. An incident/safeguarding form must be completed when the incident occurs, including witness statements, and the incident will need to be added to HRCC Incident and Accident Log, clearly stating what happened, any mitigation, and actions along with who is responsible. Full records will be kept by the Support Services Manager and CEO.
In the case of a significant incident the CEO must be informed immediately, or in their absence the Support Services Manager. An action plan will be discussed/completed by the CEO/SSM. Details of this incident will be shared with the appropriate local commissioner who can provide support as required.
The national framework defines a number of national priorities which we must investigate locally through an in-depth investigation, called a patient safety incident investigation (PSII). HRCC report on incidents and events as part of contractual reporting and meetings with the relevant local commissioner (Mid and South Essex local commissioner). In the event of an in-depth investigation being required, this will be done in collaboration with the local commissioner.
6. Engaging and Involving Patients, Families and Staff Following a Patient Safety Incident
The PSIRF recognises that learning and improvement, following a patient safety incident, can only be achieved if supportive systems and processes are in place. It supports the development of an effective patient safety incident response system that prioritises compassionate engagement and involvement of those affected by patient safety incidents (including patients, families and staff).
This involves working with those affected by patient safety incidents to understand and answer any questions they have in relation to the incident and signpost them to support as required. HRCC will involve patients and families affected by significant incidents to ensure they are informed and any questions they have are answered as part of the investigation.
The SSM will follow up with client and/or family following any serious incident. A record will be made of this. The CEO is the escalation point should this member of staff not be available.
Complementary Therapists, Counsellors and Administration Staff have access to peer support. Counsellors also have their own supervision. If a Complementary Therapist or Administration team member asks for more support immediate counselling will be arranged via the SSM. All employees have access to EAP.
The Duty of Candour is a legal duty which ensures that patients (or their families) are informed when things go wrong in healthcare. It applies to unintended or unexpected incidents which result in moderate harm, severe harm or death. This includes receiving an apology, and sharing the investigation findings and actions to prevent recurrence. HRCC hold this responsibility, with the CEO as the named Duty of Candour.
7. Patient Safety Incident Planning
PSIRF supports organisations to respond to incidents and safety issues in a way that maximises learning and improvement, rather than basing responses on arbitrary and subjective definitions of harm. Beyond nationally set requirements, organisations can explore patient safety incidents relevant to their context and the populations they serve.
HRCC aims to support this approach to the PSIRF, by:
- Resources and Training to Support PSIRF. A yearly training day is held for all Services Staff.
- HRCC will continue to work with key partners in ensuring we respond to incidents in an appropriate way according to guidance within the NHS Patient Safety Learning Response Toolkit NHS England » Patient safety learning response toolkit
- HRCC will continue to attend relevant PSIRF updates from MSE local commissioner as well as SNEE local commissioner.
Patient Safety Incident Response Plan:
- Due to the current low numbers of safety incidents reported by HRCC a Patient Safety Incident Response Plan is not deemed necessary. However this will be monitored.
- HRCC will follow the Incident and Accident Policy as well as the Safeguarding Policy when responding to incidents.
8. Responding to Patient Safety Incidents
HRCC takes responsibility to ensure all incidents and near misses are reported as required in line with national reporting standards and NHS Contracts. For the purpose of this policy an incident or near miss is described as “an unintended or unexpected event which has the potential to cause harm”.
9. Complaints and Appeals
Anyone wishing to make a complaint relating to their involvement in an investigation should be done so following the HRCC Complaints Policy and Procedure.
10. Responsibility/Accountability
Ultimate Responsibility held by: Chief Executive
Responsibility for Dissemination held by: All Line Managers
11. Compliance with Statutory Requirements
- Patient Safety Response Framework
