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Errors/ Mistakes, Adverse Events, Incidents & Near Misses  

Why it is important to be honest and to admit to and report errors

We are all human and mistakes sometimes happen. When mistakes happen it’s important to be honest and identify where errors have occurred. This will allow:

  • Action to be taken that may reduce the impact of the mistake
  • Lessons to be learnt through thinking about and agreeing what went wrong to prevent the same thing happening again
  • Clients and their families appreciate and trust staff who are honest about things that go wrong and find solutions
  • You are in breach of your contract of employment if you do not report errors
  • It may flag up the need for a change in policy and practice
  • It may flag up a training need for yourself and others to prevent a future occurrence
  • It is important to make a formal accurate record of an error so that patterns can be analysed and addressed
  • In some instances a formal complaint or legal action may arise and evidence of what happened would be required
  • Failure to flag up an error or covering it up may result in disciplinary action and/ or dismissal

Who errors should be reported to

Report all errors to your line manager as soon as possible. If the error is of a serious nature and has happened out of office hours, ring the on call phone.

How to recognise adverse events, incidents, errors and near misses (definitions adapted from SCIE descriptions)

Adverse Event – Any incident that leads to harm, loss or damage to people in care, visitors or workers. This includes a degree of disruption to service due to environmental factors such as heavy snowfall, flood or gas leak.

Error/ mistake – Misjudgement, wrong decision or wrong action. E.g. sending a client home with the wrong bag/clothing.

Incident – Any incident that leads to harm, loss or damage to clients, their family /carers or staff e.g. a client absconding as a result of staff not following the behaviour management plan.

Near Miss – An event that could have caused harm, loss and damage, but fortunately did not do so on this particular occasion.

Use to answer question 1.2f and 3.4a of the Care Certificate

What you should do in the event of an incident/ adverse event

 

  • Eliminate any immediate dangers as far as possible to make the situation safe
  • Follow the risk and Health & Safety measures which are in place, e.g. Fire Drills, etc.
  • Move people to a safe place
  • Close off an area which poses risk
  • Alert the necessary authorities e.g. the emergency services
  • Arrange for medical assistance immediately
  • Report immediately to minimise the risk of it reoccurring (inform your Manager or another senior person as soon as possible). They will arrange for necessary repairs
  • Record what happened on the Record of Visit and complete an entry in the Accident/ Incident book with a senior member of staff
  • Learn from the incident – what was the root cause? Can it be avoided by a better or improved approach? Managers will conduct a new risk assessment and make necessary amendments to the risk management measures to minimise the chance of such events reoccurring

 

What you should not do in the event of an incident/ adverse event

 

  • Ignore a concern
  • Engage in or condone poor or illegal practice
  • Continue with the same Risk Assessment if it’s control measures failed
  • Fail to put peoples Health & Safety first
  • Fail to report or record it
  • Assume someone else will take responsibility
  • Fail to follow procedure to address it if it is possible and safe to do so
  • Cover it up or destroy records or evidence
  • Engage in an activity which is not permitted within Active’s policies

Use to answer question 3.4b of the Care Certificate

What you should do in the event of an error/ mistake

 

  • Report it to your line manager or group leader and make a written record with them.
  • Assess with your manager whether the Risk Assessment and Client Support Plan was clear enough to prevent the mistake that occurred. Re-assess or re-word as necessary.
  • Learn from it.

 

What you should not do in the event of an error/ mistake

 

  • Ignore it.
  • Fail to check the current Risk Assessment/ Management Plan.
  • Continue to work in the same way without noting what caused it.
  • Cover it up or hide or destroy evidence.

 

What you should do in the event of a near miss

 

  • Report it to your line manager or group leader and make a written record with them.
  • Assess with your manager whether the Risk Assessment and Client Support Plan was clear enough to prevent the mistake that occurred. Re-assess or re-word as necessary.

 

What you should not do in the event of a near miss

 

  • Ignore it.
  • Fail to check the current Risk Assessment/ Management Plan.
  • Cover it up.

Use to answer question 1.2f of the Care Certificate

The Health and Safety at Work etc. Act 1974

This is the main piece of legislation covering occupational health and safety in the UK. It places a duty on employers and employees for the health, safety and welfare of persons in the workplace. www.hse.gov.uk/legislation/hswa.htm

The Management of Health and Safety Regulations 1999

Workplaces should have a procedure in place for recording, reporting and evaluating all serious incidents. They should take measures to avoid them happening again. www.legislation.gov.uk/uksi/1999/3242/contents/made

The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR)

This places duties on responsible persons working on the premises to report specific workplace accidents, occupational diseases and specific dangerous occurrences or near misses to their local Health and Safety Executive (HSE). www.hse.gov.uk/riddor/

The Control of Substances Hazardous to Health Regulations 2002 (COSHH) This requires employers to assess the risks of potentially harmful substances and take precautions to minimise these. They include, for example, cleaning materials and medication. www.hse.gov.uk/coshh/

The Provisions and Use of Work Equipment Regulations 1998 (PUWER)

Anyone responsible for work equipment should ensure that it is suitable for the job, well maintained, inspected regularly and only operated by well-informed and trained staff. A breach of any of these regulations is a crime in the UK and therefore needs to be reported immediately. If any person suffers harm as a result, the offender may be taken to court.

www.hse.gov.uk/work-equipment-machinery/puwer.htm

 

Use to answer question 3.4c of the Care Certificate

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