At Liverpool Women's Hospital to record and review incidents we use an electronic risk management database. Clinical and non-clinical incidents are reported by staff so that the Risk team, Clinical Governance leads and Health and Safety team can monitor trends in incidents and review the actions taken to prevent the incident happening again.
When an incident is reported a nominated member of staff will review the incident and document what action has been taken as a result of the incident. Most incidents only require a local review to manage them, some incidents are more complex and require an investigation known as a formal review which involves at least two members of staff from different disciplines, who have not been directly involved in the incident, (for example a senior nurse and a senior doctor) to review the incident, draw conclusions and decide if any action is required.
Sometimes an incident is classed as a Serious Incident which we have to report to our Clinical Commissioners. If a Serious Incident is declared then a detailed investigation called a "Root Cause Analysis" (RCA) is conducted and a report is drawn up of the findings and the actions required to address the issue.
An important part of any investigation is to ensure that the staff and patients, or their relatives / carers, are given feedback on the incident and the findings so that as an organisation we can learn lessons to improve safety for patients, the public and our staff.
For more information on RCAs please see the 'Serious Incident / RCA Patient Information Leaflet'