As part of the trust’s patient safety and risk management strategy, South Tees Hospital NHS Foundation Trust has a system of non–punitive reporting of incidents. These incidents may include errors, omissions, hazards, accidents etc. The trust aims to improve all aspects of care on a continuous basis from the perspective of patients, staff, carers and relatives.
Adverse event reporting, monitoring and action planning is a significant part of the governance and quality agenda. The approach taken by the trust is one of avoiding blame of individuals and encouraging an open and honest approach to the reporting of adverse events.
It is expected that all staff in the trust will report all untoward and near miss events of whatever cause, via the trust incident reporting system. To encourage all staff to have the confidence to report adverse events and near misses.
The trust board, management group and all other leaders within the organisation are committed to developing a culture that welcomes the knowledge of such events in order to improve patient care, the services offered within the trust and the working environment for staff.
In the majority of incidents reported the subsequent review would not lead to any disciplinary action. The disciplinary process may be initiated where there has been a conscious breach of policy, malicious or criminal intent or gross professional misconduct. Also staff who make a conscious decision not to report a serious adverse event may face disciplinary action.
There are a number of trust policies giving instruction and guidance on the reporting and investigation of incidents. Trust policies are available to the public under the Freedom of Information Act 2000.
Risk assessment and risk register
The Department of Health’s report ‘Building a Safer NHS’ (April 2001) highlighted the importance of not only learning from incidents which already happened but also that it is essential to identify factors that could affect patient safety and take steps to reduce these risks.
Risk assessment is the process that helps the trust understand the range of risks that are inherent within the service we provide, the level of ability to control these risks, their likelihood of occurrence and the potential impact they may have on patients, staff and the service as a whole.
Risk assessments are conducted by staff who have received the relevant training, and made using the approved assessment tool and documentation within the quality assurance risk assessment toolkit.
Each directorate or division takes ownership of their own risks and where they cannot be managed/controlled, or where the risk remains high, these are communicated to the assistant director of nursing and patient safety and entered onto the trust risk register. Register reports are received by the various committees within the organisation where risks are discussed and progress monitored.