NABH incident reporting and quality improvement procedure template

1Purpose

1. 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.
2. 1.2Staff report without fear of blame, and the clinic looks for causes in its systems before it looks at individuals.

2What to report

1. 2.1Any event that harmed or could have harmed a patient, a visitor or a member of staff, including near misses.
2. 2.2Medication errors, missed or delayed results, records shared in error, and any breach of patient data.

3Reporting

1. 3.1The person who sees the incident reports it to [Name, role] the same day, and makes the patient safe first.
2. 3.2The report records what happened, when, where, who was involved, and what was done at once.
3. 3.3Where a patient was harmed, the patient is told, given an apology and kept informed of what the clinic finds.

4Investigation

1. 4.1[Name, role] grades each incident by severity within [2] working days, and decides the level of review.
2. 4.2The review uses the record and the audit trail to establish what happened, in order, with times and names.
3. 4.3The review names the causes, the actions, an owner and a date for each action.

5Learning

1. 5.1Each incident and its actions are discussed at the next governance meeting, and the discussion is minuted.
2. 5.2What changed is shared with every member of staff, and checked [3] months later to confirm it held.

6Review

1. 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.
2. 6.2Each review is recorded with the date, the reviewer and what changed, and the previous version is kept.
3. 6.3Staff are told of each change, and their acknowledgement is recorded.

7Where this sits in the NABH framework

• Infection Prevention and Control, and Patient Safety and Quality ImprovementPSQ.1. The organisation implements a structured patient safety programme.
  PSQ.7. Incidents are collected and analysed to ensure continual quality improvement.
• Responsibility of Management, Facility Management and Safety, and Human Resource ManagementROM.6. Management ensures that patient-safety aspects and risk-management issues are an integral part of patient care and hospital management.