[Clinic name]
Controlled document
[Address]
[Registration or licence number]
Incident and near miss reporting procedure
1Purpose
- 1.1This procedure sets out how [Clinic name] reports, investigates and learns from incidents and near misses, so that each one leads to a change that sticks.
- 1.2Staff report without fear of blame, and the clinic looks for causes in its systems before it looks at individuals.
2What to report
- 2.1Any event that harmed or could have harmed a patient, a visitor or a member of staff, including near misses.
- 2.2Medication errors, missed or delayed results, records shared in error, and any breach of patient data.
3Reporting
- 3.1The person who sees the incident reports it to [Name, role] the same day, and makes the patient safe first.
- 3.2The report records what happened, when, where, who was involved, and what was done at once.
- 3.3Where a patient was harmed, the patient is told, given an apology and kept informed of what the clinic finds.
4Investigation
- 4.1[Name, role] grades each incident by severity within [2] working days, and decides the level of review.
- 4.2The review uses the record and the audit trail to establish what happened, in order, with times and names.
- 4.3The review names the causes, the actions, an owner and a date for each action.
5Learning
- 5.1Each incident and its actions are discussed at the next governance meeting, and the discussion is minuted.
- 5.2What changed is shared with every member of staff, and checked [3] months later to confirm it held.
6Review
- 6.1[Name, role] reviews this document every [12] months, and sooner after an incident, a complaint or a change in the regulator's requirements.
- 6.2Each review is recorded with the date, the reviewer and what changed, and the previous version is kept.
- 6.3Staff are told of each change, and their acknowledgement is recorded.
7Where this sits in the AAAHC framework
- SafetySAF.110 and SAF.120, reporting near misses and adverse incidents without fear of reprisal
SAF.130, review of every reported incident and corrective action - QualityQUA.210, risk and quality findings carried into the QI program with measurable goals
AAppendix, AAAHC QI study, six components
- A.1Purpose, the problem ______ Who is affected ______ Baseline ______
- A.2Goal, the target ______ By ______ Benchmark ______
- A.3Analysis, the root causes ______
- A.4Actions, what changed ______ When ______ Owner ______
- A.5Remeasurement, the result ______ Goal met, yes or no ______ Next cycle ______
- A.6Communication, governing body review on ______ Staff told on ______