Risk Management

P_RM_02 Risk Management Strategy

This Policy has been developed in line with the organisation's approach to risk management, to provide a framework for staff to ensure the appropriate management and review of organisation wide risks.

The purpose of this policy is to ensure that risks to the quality and delivery of patient services and care are minimised, to protect the services, reputation and finances of the organisation, to create a culture where staff acknowledge risk as the responsibility of everyone and to ensure that the organisation meets its statutory obligations.

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P_RM_06 Serious Untoward Incident Policy

A serious incident is defined by the National Patient Safety Agency as:

  • Unexpected or avoidable death of one or more patients, staff, visitors or members of the public;
  • Serious harm to one or more patients, staff, visitors or members of the public or where the outcome requires life-saving intervention, major surgical/medical intervention, permanent harm, or will shorten life expectancy, or result in prolonged pain or psychological harm (this includes incidents graded under the NPSA definition of severe harm);
  • A scenario that prevents or threatens to prevent a provider organisation's ability to continue to deliver health care services, for example, actual or potential loss of personal/organisational information, damage to property, reputation or the environment, or IT failure;
  • Allegations of abuse;
  • Adverse media coverage or public concern for the organisation or the wider NHS;
  • One of the core set of "Never Events" as updated on an annual basis

Promoting patient safety by reducing errors is a key priority for the NHS. This responsibility is highlighted by Department of Health guidance, Organisation with a Memory (DOH 2000) and Building a Safer NHS (DOH 2001) which, collectively, emphasise the need to learn from adverse events. The Organisation must ensure that Serious Incidents (SIs) are identified, reported and managed in an effective and timely way.

Key words from policy:

Emergency planning, Major incidents, serious incidents, mortality, never events, professional misconduct, terrorism, chemical, biological, radiological or nuclear incidents, unexpected death, serious harm or injury, safeguarding children and vulnerable adults, loss of confidential information, serious adverse drug reactions, legal incidents, litigation, substance misuse, violence towards health care staff, risk evaluation, risk register, root cause analysis, practitioner performance, inquest.


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P_RM_05 Procedure for the Investigation of Incidents, Complaints and Claims

Lincolnshire Community Health Services NHS Trust recognises that in a service as large and complex as the NHS, incidents, complaints and claims do occur. However, the Trust has a responsibility to investigate these events to understand their root causes and to recommend actions and sustainable solutions to help minimise the chance of the same or a similar event recurring in the future.

The Trust recognises that most incidents, complaints and claims occur because of problems with systems rather than individuals. Therefore, the Trust supports the view that the response to an incident, complaint or claim should not be one of blame and retribution but of organisational learning with the aim of encouraging participation in the overall process and supporting staff, rather than exposing them to recrimination. Therefore, the Trust is committed to developing a fair blame culture and to encouraging a willingness to admit mistakes without fear of punitive measures.

This procedure document should be read in conjunction with the Claims Policy, Being Open Policy, Complaints Policy, Investigation Policy, Risk management Strategy and Incident Reporting Policy.

This policy has been developed to demonstrate the Trust's commitment to improving safety by learning lessons from the investigation and analysis of incidents, complaints and claims. Lincolnshire Community Health Services NHS Trust has individual policies and procedures that cover the reporting and management of incidents, complaints and claims and being open with our staff, patients, carers and the public. This document sets out the process for investigation of incidents, looking at the underlying causes and identifying actions to prevent a recurrence and understand how loss can be minimised.

Key processes:  Root Cause Analysis, Datix, Risk Management, PALS,

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P_RM_01 Incident Reporting

This policy is consistent with guidance issued by the Department of Health in June 2000 entitled An Organisation with a Memory: Report of an expert group on learning from adverse events in the NHS, which drew attention to the scale of potentially avoidable events within the NHS and Building a safer NHS for Patients published in April 2001, which sets out the Government's plans for promoting patient safety.

"Doing Less Harm", (NPSA 2001) provided a framework for incident reporting which has underpinned the development of systems and processes in the Lincolnshire Community Health Services.  Incident Reporting Compliance Requirements and Professional & Health Service Guidelines and Standards are shown in Appendix 1.  This policy should be read and used in conjunction with the Lincolnshire Community Health Services Risk Management Strategy, Major Incident Policy, Serious Incident Policy and related policies identified in paragraph 12.

Lincolnshire Community Health Services is committed to reducing all adverse incidents (both clinical and non-clinical) involving all those who may be affected by the organisation's activities.

The intention is not to apportion blame but to create an environment that encourages staff to report incidents and near misses, the awareness of which may serve to alert management and other staff to areas of potential risk at an early stage and enable avoiding action to be taken. In this context, valuable learning from incidents and near misses, can take place.

This policy covers all adverse, serious incidents and near misses and the following reporting systems:-

  • Adverse Incidents
  • RIDDOR reportable incidents
  • Medical Devices
  • Violence and Aggression
  • Serious Incident Reporting Policy
  • Root Cause Analysis (RCA)
  • Datix investigation form (IR2)


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Root Cause Analysis Toolkit - Incident Investigation

Getting to the Root of the Problem - How Can Root Cause Analysis Help

The purpose of this toolkit is to support the delivery of the "Getting to the Root of the Problem" root cause analysis presentation at the Partners in Patient Safety Conference 2009/10.  The document describes the stages in the root cause analysis process and, provides an example of how this information may be pulled together to provide a formal report, which can be used to support communication of key findings within practice.


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