Serious untoward incident reporting

Since April 2010, NHS trusts have had a statutory duty to report all serious untoward incidents (SUIs) so that lessons can be learned across the health service.

Responsibilities in reporting SUIs

  • All hospital trusts have their own local systems in place for reporting adverse incidents.
  • Some hospitals employ separate systems for reporting 'near misses' from those cases which may result in harm to a patient.

Taking part in investigations

All doctors also have an ethical obligation to contribute to SUI investigations which are generally carried out by the trust.

While the object of such an investigation should not be to cast blame on an individual, errors may be identified in an individual's practice. It's understandable that health professionals - particularly junior doctors - might feel vulnerable the first time they are involved in an SUI and are asked to produce a report on their actions.

Scenario

During a hectic night shift, an FY1 doctor was asked to prescribe an evening warfarin dose for an elderly patient. As he was busy, he asked the nurse in charge of the ward to look up that day's INR result and he prescribed the warfarin based on that result.

Unfortunately, there had been a misunderstanding and the INR result was for another patient, so the warfarin dose prescribed was too high. While the patient came to no harm, the incident was reviewed as an SUI and the doctor was required to prepare a report about what had happened.

Preparing a report - general principles

  • Refer to the relevant clinical records when preparing a statement.
  • Identify yourself at the beginning of your report with your full name, professional qualifications, experience, status (eg FY2 doctor). Describe the capacity in which you reviewed the patient and whether this was with another member of the healthcare team.
  • Write in the active voice; for example, 'I prescribed...' rather than 'X was prescribed'.
  • The report should be detailed and capable of standing on its own. Don't assume that the reader of the report has any background knowledge of the case or will have access to the records.
  • List the documents you relied on in giving your report and also make clear whether any aspects of your report are based on your memory of events or your usual practice.
  • Give a factual description of the chronology of events as you saw them, referring to your clinical notes as a framework.
  • Describe each and every consultation or contact with the patient in turn and make reference to your working diagnosis at each stage, reasons for your decisions and any action that you took, such as discussion with senior colleagues.
  • Avoid the use of medical abbreviations. For example, BP should be written as blood pressure and SOB as shortness of breath.
  • Explain technical terms and interpret results so that the report can be understood by someone without knowledge of the specialty.
  • Any reference to medication should include the name of the medication, the type, for example antidepressant or antihypertensive, as well as the dose and route of administration.

If you have any doubt about whether or how to report an incident, seek advice from a senior colleague or the MDU.

This guidance was correct at publication 22/03/2018. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

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