Healthcare records review eg Global Trigger Tool or Mortality review

1. Healthcare records review eg Global Trigger Tool or Mortality review Adverse event found by reviewer Trigger found by reviewer Adverse event agreed by Consultant arbitrator Immediate threat to patient safety Patient was harmed Trigger only - no immediate threat to patient safety Incident form completed on Datix – usual process applies Escalate via usual SUI process, contact: CEO, CMO, CN, Head of Legal Services, Head of Risk Adverse event and incident ID number reported by Consultant arbitrator to relevant Consultant/Clinical Governance lead Trigger that may be frequent or widespread Trigger that is unlikely to occur regularly Review by Head of Patient Safety with aggregation of Complaints and incidents data Consider an audit and report to Clinical Audit Committee Review on an individual basis and consider contacting patient or family following Being Open Policy – check with Head of Legal Services Incident reviewed at Clinical Governance and actions recorded and fed back to Patient Safety Council Report lessons learned to Patient Safety Council Hester Wain Ver 2. Jan 2010 Adapted from J Parfitt, WEHCT (June 2008)