NHRA sentinel event reporting and investigation procedure template

1Purpose

1. 1.1This procedure sets out how [Clinic name] recognises, reports and reviews sentinel and serious untoward events.

2Reporting

1. 2.1The person who sees the event makes the patient safe first, then tells the Chief Medical Executive at once.
2. 2.2A sentinel event reaches NHRA within 5 working days, and the full internal investigation, with root cause analysis, within 45 days.
3. 2.3The report records what happened, when, who was involved and what was done at once.

3Review

1. 3.1The Chief Medical Executive leads a review of each event, using the record and the access log, with times and names.
2. 3.2The review names the causes, the actions, an owner and a date for each action, and is kept on file.

4Learning

1. 4.1What changed is shared with every member of staff, and checked [3] months later to confirm it held.
2. 4.2Drug formulary, sterilising, equipment and fire drill records are reviewed at the same time where the event touches them.

5Review

1. 5.1The Chief Medical Executive reviews this document every [12] months, and sooner after an incident, a complaint or a change in the regulator's requirements.
2. 5.2Each review is recorded with the date, the reviewer and what changed, and the previous version is kept.
3. 5.3Staff are told of each change, and their acknowledgement is recorded.

6Where this sits in the NHRA framework

• Incidents and sentinel eventsAn incident reporting policy, process and form that all staff know
  Sentinel events reported to NHRA within 5 working days
  The full internal investigation, with root cause analysis, within 45 days