Report an SE here → Significant event reporting form
What is a Significant Event (SE)?
Significant Events are events which could have, or did, lead to harm for one (or more) of our patients or staff members. These events are unintended and accidental, but could be due to ignorance, neglect, or a poorly considered process. Investigation is vital to understand how the SE happened, and to avoid it happening again in the future.
Significant Event Reporting
All staff have a responsibility to identify and report SEs to promote learning and improvement within the practice.
SEs should be reported by filling in our Significant event reporting form (the form can also be found on the Penrose Portal homepage, under Links).
The SE report will be reviewed and assigned to an appropriate person to investigate (see below).
Internal reporting
Some types of SEs also need to be reported elsewhere within Penrose Health…
- Safeguarding → contact your site 👤 Safeguarding Lead / Deputy (see also Adult Safeguarding and Child Safeguarding)
- Infection control → contact the 👤 Nursing Lead / Infection Prevention and Control (IPC) Lead (see also Infection Prevention & Control)
- Notifiable diseases → urgently notify any available senior clinician (see also Notifiable Diseases Reporting Procedure (NOIDs))
- Medication incidents → contact 👤 Controlled Drugs Accountable Officer (see also Controlled Drugs or Allergies & Adverse Reactions)
- Information governance (IG) → fill in the Information Incident Reporting Form and contact 👤 Senior Information Risk Officer (SIRO) / IG Lead or Caldicott Guardian or Data Protection Officer (DPO) (see also Incident Reporting)
- Health & safety / facilities → fill in the Workplace Issues Form or Facilities Issues Form (see also Health, Safety and Environment)
See Key People to Know if you’re not sure who to contact.
External reporting
This is provided for reference - the person investigating the SE will submit an external report, if necessary.
Occasionally, we may also need to inform an external body…
- Adverse medication reactions → should be reported to the Medicines & Healthcare products Regulatory Agency (MHRA) (see Allergies & Adverse Reactions)
- Notifiable diseases → should be reported to South London UKHSA HPT (see Notifiable Diseases Reporting Procedure (NOIDs))
- Health & Safety
- Patient-related → the CQC require us to report events that affect the health, safety and welfare of people who use our services (e.g. a serious injury to a service user, an allegation of abuse, incidents reported to the police, any event that stops or may stop the registered person from running our services safely and properly)
- Staff-related → if an accident happens which is work-related and results in a ‘reportable injury’, this must be reported under RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations)
- Professional practice → quality alerts should be submitted through DCIQ: NHS South East London ICB Quality Alerts reporting form (see Quality Alerts)
- Deaths → the CQC require us to report deaths that happen whilst we are providing care, or if a patient dies within two weeks of a consultation that may contribute to their death and their death could not be attributed to the course expected of their illness (see also Reporting Patient Deaths)
Investigations
Once we receive an SE report, it will be assigned to an appropriate person to investigate (usually the team lead for whichever team/individual was most centrally involved in the SE).
All cases will be investigated within 7 calendar days.
The investigation will look into:
- What happened and why?
- How could things have been different?
- What can we learn from what happened?
- What needs to change?
Outcomes
Following the investigation, there may be a variety of outcomes depending on the situation. They may include:
- speaking directly to team or individual involved
- discussing the event at a team meeting / PLT / clinical meeting
- updating any inadequate or ambiguous processes
- offering additional support to individuals involved (e.g. through a PIP)
- posting learning points in the Penrose Scroll newsletter
- in very rare cases of misconduct, taking disciplinary action