PROTOCOL FOR MONITORING OF ADVERSE PATIENT
INCIDENTS DUE TO INFECTION
MONITORING OF ADVERSE PATIENT INCIDENTS DUE
Adverse patient incidents arising from infection,
including outbreaks of healthcare associated infection may vary
considerably in size, extent and impact. It will be entirely appropriate
for many minor adverse patient incidents to be managed wholly
within the Trust. However, where such incidents have a significant
impact on the ability of the Trust to admit and discharge patients
or undertake its routine activities, it is imperative that the
Regional Directors of Public Health (RDsPH) and the relevant Regional
Epidemiologist (RE) are kept fully informed of events in a timely
The purpose of such reporting is to ensure that:
all the necessary resources are brought
to bear without delay in order to effectively control the incident
whilst maintaining continuity of services to the local population;
information on incidents is used
to assist in determining the adequacy of service provision, including
infection control arrangements;
to ensure that lessons learnt are
incorporated into revised strategic arrangements for infection
to inform Ministers, Parliament and
An adverse patient incident arising from infection
is defined as any event or circumstance arising during NHS care
in which infection results in unintended or unexpected harm to
Reportable adverse patient incidents are those:
that result in significant morbidity
or mortality; and/or
involve highly virulent organisms;
are readily transmissible; and/or
require control measures that have
an impact on the care of other patients, including limitation
of access to healthcare services;
involve convening an outbreak control
committee (OCC). The decision as to the need to call an OCC will
be that of the Hospital Control of Infection Officer (HCIO) and/or
the Consultant in Communicable Disease Control (CCDC).
Reporting only when events occur
Guidance issued by DH and the NHS National Patient
Safety Agency (NPSA) require that adverse events to patients should
be graded according to the actual impact on the patients and the
potential future risk to patients and the organisation.
For practical purposes, it is the decision of
the HCIO, usually in conjunction with the CCDC, to formally convene
an OCC that defines the incident as being of such significance
as to require reporting to the RDPH and RE.
It should be noted that the NPSA should also
be informed of adverse events categorised as Red. See Special
All incidents meeting the DEFINITION should
be reported to RDPH and RE.
Incidents that are categorised as Red using
NPSA criteria should be reported to NPSA.
Date of onset of first case/of exposure(s).
Number of confirmed and suspected
Outcomesill, recovered, deaths.
As part of its conduct in managing an incident
OCCs are required to produce a final report of the outbreak, normally
within 30 days of its conclusion. This report will be sent to
the RDPH and RE. Information for monitoring purposes will be provided
as an annex to this report in a specified format. Aggregated summary
data of incidents will be provided by the RE to the RDPH annually.
Aggregated summary data of incidents will be
provided annually to DH by CDSC.
To ensure that adequate resources
are made available for the control of outbreaks of infection.
To co-ordinate the management of
outbreaks involving more than one Trust or PCT.
To ensure that lessons learned from
individual outbreaks are incorporated into revised guidelines
or infection control.
Time is of the essence in the communication
of information. The Infection Control Team should notify the Chief
Executive, the CCDC and the Director of Public Health (DPH) of
the problem at the time the incident is first recognised. The
OCC should provide a preliminary report within three working days.
The RDPH and the relevant RE should be informed that an adverse
incident has occuredespecially when more than one Trust/PCT
The RDPH will be responsible for ensuring that
appropriate dissemination within DH, whilst the RE will ensure
appropriate communications within CDSC. Other agencies may also
need to be informed viz: The Health and Safety Executive, Department
of Food, Environment and Rural Affairs, the Medical Devices Agency.
Patients Potentially at risk
It will need to be borne in mind that some incidents
only become apparent after the event eg HIV or Hepatitis B and
C infected health care workers involved in exposure prone procedures.
Because public concerns can be raised in such circumstances, it
is important that the RDPH and relevant CCDC are notified of the
problem at an early stage.
Frequency of reporting
Reports on the progress of the incident should
be provided to the Chief Executive of the Trust and the relevant
DPH on a regular and timely basis. The Chair of the OCC will ensure
that copies of these reports are sent to the RDPH and RE, usually
this will be undertaken by the CCDC.
Final report of outbreak control committee
OCCs are required to produce a final report
on the incident. This report will include:
A description of the incident, including
investigations to determine the cause of the incident.
An account of the actions taken to
control the problem.
An account of actions taken to minimise
the chance of a recurrence of the problem.
The RDPH will, in conjunction with Regional
Performance Managers, audit these arrangements on a regular basis.
A summary of adverse patient events due to infection will form
part of the annual report provided by the OCC to the Chief Executive
of the Trust.
NPSA categorisation of incidents
The following guidance is given to illustrate
how incidents of infection can be categorised in accordance with
Red Incidents: involving very high risk
to patients eg:
death of several patients in the
same ward/hospital over the same period of time due to a related
hospital acquired infection involving
large numbers of patients involving closure of ITU, one or more
wards, or resulting in suspension of clinical activity.
Orange Incidents: these are high risk
outbreak of infection with alert
organisms (eg MRSA, GRE, Clostridium difficile) or other
organisms which local surveillance has indicated may be a cause
for action. Such outbreaks may be new, or continuing despite appropriate
the actual or potential transfer
of blood-borne viral infections from healthcare workers to patients
leading to look back reviews;
failure of decontamination or sterilisation
of surgical instruments.
Yellow Incidents: of moderate severity,
localised outbreaks of infection
in several beds in one or more wards (not necessarily leading
to ward closure);
increase in observed over expected
ratio for wound sepsis.