Purpose The Framework to support the NHS to ensure that robust systems are in place for reporting, investigating and responding to serious incidents so that lessons are learned and appropriate action taken to prevent future harm. The Framework is into three parts; Part One: Definitions and Thresholds - sets out what a serious incident is and how serious incidents are identified. This section also outlines how the Framework must be applied in various settings. Part Two: Underpinning Principles - outlines the principles for managing serious incidents. It also clarifies the and responsibilities in relation to serious incident management, makes reference to legal and regulatory requirements and signposts to tools and resources. - outlines the process for Part Three: Serious Incident Management Process conducting investigations into serious incidents in the NHS for the purposes of learning to prevent recurrence. It covers the process from setting up an investigation team to closure of the serious incident investigation. It provides information on timescales, signposts tools and resources that support good practice and provides an assurance Framework for investigations. The Framework aims to facilitate learning by promoting a fair, open, and just culture that abandons blame as a tool and promotes the belief that cannot simply be ‘incidents linked to the actions of the individual healthcare staff involved but rather the system in which the individuals were working. Looking at what was wrong in the system helps organisations to learn lessons that can prevent the incident recurring’. It is recognised that serious incidents that require investigation extend beyond those which affect patients directly and include incidents which may indirectly impact patient safety or an organisation’s ability to deliver ongoing healthcare. The Framework describes the process for undertaking systems-based investigations that explore the problem (what?), the contributing factors to such problems (how?) and the root cause(s)/fundamental issues (why?). It endorses the recognised approach applied within the NHS (currently referred to as Root Cause Analysis investigation) and recognises that incidents’ span a vast range of healthcare providers and ‘serious settings, extending into social care and the criminal justice system. The Framework acknowledges the interfaces with organisations, particularly those with a statutory responsibility to investigate specific types of incidents which may involve the delivery of healthcare and therefore can coincide with serious incident investigations led by the health service. In doing so, it recognises that a variety of investigation methodologies may be applied and promotes the ever increasing need to work collaboratively in an effort to draw lessons to inform systematic learning and improvement. Local operational guidance for serious incident management (within commissioning and provider organisations) must be consistent with this Framework.
Purpose The Framework to support the NHS to ensure that robust systems are in place for reporting, investigating and responding to serious incidents so that lessons are learned and appropriate action taken to prevent future harm. The Framework is into three parts; Part One: Definitions and Thresholds - sets out what a serious incident is and how serious incidents are identified. This section also outlines how the Framework must be applied in various settings. Part Two: Underpinning Principles - outlines the principles for managing serious incidents. It also clarifies the and responsibilities in relation to serious incident management, makes reference to legal and regulatory requirements and signposts to tools and resources. Part Three: Serious Incident Management Process - outlines the process for conducting investigations into serious incidents in the NHS for the purposes of learning to prevent recurrence. It covers the process from setting up an investigation team to closure of the serious incident investigation. It provides information on timescales, signposts tools and resources that support good practice and provides an assurance Framework for investigations. The Framework aims to facilitate learning by promoting a fair, open, and just culture that abandons blame as a tool and promotes the belief that ‘incidents cannot simply be linked to the actions of the individual healthcare staff involved but rather the system in which the individuals were working. Looking at what was wrong in the system helps organisations to learn lessons that can prevent the incident recurring’. It is recognised that serious incidents that require investigation extend beyond those which affect patients directly and include incidents which may indirectly impact patient safety or an organisation’s ability to deliver ongoing healthcare. The Framework describes the process for undertaking systems-based investigations that explore the problem (what?), the contributing factors to such problems (how?) and the root cause(s)/fundamental issues (why?). It endorses the recognised approach applied within the NHS (currently referred to as Root Cause Analysis investigation) and recognises that ‘serious incidents’ span a vast range of healthcare providers and settings, extending into social care and the criminal justice system. The Framework acknowledges the interfaces with organisations, particularly those with a statutory responsibility to investigate specific types of incidents which may involve the delivery of healthcare and therefore can coincide with serious incident investigations led by the health service. In doing so, it recognises that a variety of investigation methodologies may be applied and promotes the ever increasing need to work collaboratively in an effort to draw lessons to inform systematic learning and improvement. Local operational guidance for serious incident management (within commissioning and provider organisations) must be consistent with this Framework.
serious-incidnt-framwrk-upd2.docx