Datix Reporting for Nursing and Medical Staff in the Neonatal Service

The Neonatal Service is committed to the delivery of safe, effective patient care in a safe working environment and to preventing injury and ill health arising from its undertakings.

Appropriate management of adverse events is a key component of the overall risk management process. Effective risk management is not about eradicating or avoiding risk altogether, but minimising the risk and its impact to ensure that when things do go wrong, learning is maximised and shared so that repetition can be avoided in the future.

Adverse Events, including near misses, provide a rich source of key information on risk and recovery; the neonatal unit therefore strives to provide a physical and cultural environment which promotes Adverse Event Reporting.

What events should be reported?

Any adverse event/near miss, event or circumstance arising during NHS service provision that could have or did lead to unexpected harm, loss or damage should be reported. Harm need not always be of a physical nature, it may be emotional or psychological. Verbal, emotional abuse and child protection issues should also be reported.

The following document details the triggers for Datix reporting in the neonatal unit and the subsequent process of review.

Specific Neonatal Triggers for Datix reporting

• Neonatal death
• HIE grade 2 or 3 in infant ³34weeks
• Meconium aspiration syndrome (typical CXR changes and FiO2>30%)
• Undiagnosed congenital anomaly
• Birth injury
• Unplanned term admission requiring any ventilatory support or volume resuscitation
• Bilirubin at or over exchange level
• Hypothermia <36 C (Not Therapeutic Hypothermia)
• Hypoglycaemia <1mmol/l or symptomatic hypoglycaemia < 2 mmol/l
• Failure to take cord bloods for ongoing neonatal care (does not include cord pH)
• Refusal of in utero or ex utero transfer due to capacity/staffing (from any unit)
• Overcapacity
• Unexpected readmission to the neonatal unit
• Baby abduction
• Abandoned baby
• Missed/delayed blood spot screening
• Missed/delayed retinopathy screening
• Administration of the wrong maternal breast milk

Generic Triggers for Datix reporting

• MRSA colonisation or infection
• Discharge against medical advice
• Staff shortage
• Medicine administration error
• Medicine prescription error
• Adverse medicine reaction
• Incident resulting in harm to staff
• Incidence of violence/aggression to staff
• Equipment failure

Please remember that this is only a shortlist. If you think that anything preventable by policy review has contributed to potential or actual harm to a patient or staff please complete a Datix.

Neonatal Services Guide to completing a Datix form

1. Choose Datix from NHSLothian Intranet homepage and enter date
2. Harm: select Severity of Actual Harm as indicated in Table 1
3. Division: University Hospitals Services (Acute)
4. Management team: Women’s and Childrens
5. Service area: Women’s services- Neonatal
6. Site: Royal Infirmary Little France or St Johns
7. Choose department, ward or location where incident happened
8. Complete incident SBAR
9. Select the Main Category and then appropriate subcategory as indicated by Table 2 below
10. Enter your own details and submit

Table 1. Guide to rating severity of harm

Table 2. Main category and subcategories of common neonatal incidents

Main categories - select the appropriate sub-category

• Neonatal death
• HIE grade 2 or 3 in infant ≥34weeks
• Meconium aspiration syndrome (typical CXR changes and FiO2>30%)
• Undiagnosed congenital anomaly
• Birth injury
• Unplanned term admission requiring any ventilatory support or volume resuscitation
• Bilirubin at or over exchange level
• Hypothermia <35C (Not Therapeutic Hypothermia)
• Hypoglycaemia <1mmol/l or symptomatic hypoglycaemia < 2 mmol/l
• Failure to take cord bloods for ongoing neonatal care (does not include cord pH)
• Refusal of in utero or ex utero transfer due to capacity/staffing
• Overcapacity
• Unexpected readmission to the neonatal unit
• Baby abduction
• Abandoned baby
• Missed/delayed blood spot screening
• Missed/delayed retinopathy screening
• Administration of the wrong maternal breast milk

Main category- Infection Control
MRSA colonisation or infection	Enter under ‘Healthcare associated MRSA’
Main category- Discharge
Discharge against medical advice	Enter under ‘Patient self-discharge’
Main category- Staffing issue
Staff shortage	Enter under ‘staff shortage’
Main category- Medication
Medicine administration error	Choose appropriate subcategory
Medicine prescription error	Choose appropriate subcategory
Adverse drug reaction	Choose appropriate subcategory
Other incidents
Incident resulting in harm to staff	Can enter under ‘Burns/scalds’, ‘clinical sharps’, ‘electric shocks’, ‘falls-non patient’, ‘hit by/equipment’, ‘manual handling’, ‘occupational illness’ etc
Incidence of violence/aggression to staff	Enter under violence/aggression/ abuse/harassment
Equipment failure	Enter under ‘Equipment’

 

Process of review

In all incidents there will be care to preserve the anonymity of staff involved but this cannot be guaranteed. Where this cannot be guaranteed be reassured that such incident reviews are treated as confidential.

The following flowchart outlines the process for review of incidents reported through Datix and is explained in the subsequent text.

 

1. Medication Datix

Any Datix relating to medicines (administration and prescription errors, administration of the wrong breast milk or an adverse drug reaction) will be reviewed by the Clinical Manager and Ward Coordinator. This may also involve the consultant attending for that area.

Unless the incident has complex features or has resulted in significant harm, the responsible staff member will be asked to meet with the Ward Coordinator, Clinical Manager or Medical Consultant to discuss.

• If no professional practice issues are identified the incident will be closed. The responsible individual may be required to prepare a reflective note or a piece of evidenced learning for their eportfolio or eKSF.
• If professional practice issues are identified, the relevant procedural pathway will be undertaken and the incident closed.

 

If the incidence has complex features or has resulted in major harm, this will be reviewed at the Neonatal Unit Incident Meeting (weekly SCRH, quarterly St Johns). In most cases, if on days off or leave, the staff member involved will be notified on return to work. Occasionally it may be necessary for patient safety issues to contact the member of staff prior to return to work.

It will not be routine or usual to ask staff to prepare a statement following a medicine datix. Staff may be still required to provide statements in the following scenarios:

1. if the incident has resulted in death or major harm
2. if the incident leads to concern about professional practice
3. if the incident has led to a complaint
4. if the incident is complex and requires review at the neonatal incident meeting

Learning from events may be additionally supported by a safety brief or practice reminder, training support or referral to the Quality Improvement Programme.

Individual staff may request feedback on any incident they have submitted, but confidentiality of individuals will be respected and will not be breached in any feedback given.

2. Non Medicine Datix

Datix entries not relating to medicines and not in the category death or major harm, will be reviewed by the Clinical Manager and Ward Coordinator and either closed or referred to the Neonatal Unit Incident Meeting. Staff may be asked to prepare a statement to inform this process.

Following this meeting, an incident may either be closed or result in a meeting between the responsible individual and the Clinical Manager or Medical Consultant or be escalated to a full investigation.

Learning from events may be additionally supported by a safety brief or practice reminder, training support, referral to the Quality Improvement Programme and/or the responsible individual will prepare a reflective note for their eportfolio or eKSF.

3. Death or major harm

All cases in this category will be discussed at the Neonatal/Maternity Triage meeting where cases that are not identified as having contributing factors relating to quality of care will be closed. The rest will be escalated to a full investigation, following which the case will be closed. In all incidents which are escalated to a full investigation, relevant staff will be asked to prepare statements to inform the process (see learning from Neonatal Deaths below).

Learning from Neonatal Deaths

Purpose of neonatal death review:

1. to identify aspects of care delivery which may or may not have contributed to outcome
2. to escalate any cases requiring a full investigation
3. to identify cause of death to inform MBBRACE data
4. to identify issues of clinical management that may inform ongoing quality of care for all babies
5. to feedback to the service and individuals

Process of learning and review

All neonatal deaths will be recorded through Datix.

All neonatal deaths will be reviewed in 3 separate forums which as well as serving separate functions, provide different learning opportunities:

1. Maternity case review meeting- All neonatal deaths in Lothian will be reviewed at a fortnightly maternity risk review meeting by at least one obstetrician, one neonatologist, one senior midwife and one neonatal nurse. Deaths will be coded at this meeting and this data will inform the MBRRACE process. There will be two outcomes (see flowchart ‘Maternity & Neonatal Services Datix Management System, Risk Review Process & Learning’):

1. 1. Escalation to a full investigation where aspects of care are deemed to have contributed to outcome
   2. Recommendation for closure by the senior management team if no aspects of care delivery have been identified as contributing to outcome

2. Perinatal Mortality meeting- All neonatal deaths in Lothian will be reviewed at a monthly perinatal mortality meeting. At this forum there will be synthesis of obstetric, neonatal, pathology and other relevant data to achieve a final diagnosis.

3. Neonatal Mortality Grand Round- All neonatal deaths in Lothian will be reviewed in a monthly forum at Grand Round. This will include a case review of quality of neonatal care with identification of broader issues relevant to care of all babies. Quorum will be at least two consultant neonatologists and two senior nurses. Attendance and minutes of this meeting will be submitted to the Maternity Risk Team. Lessons learned where identified will be uploaded to the Datix action plan by administrative staff.

Lessons learned from all deaths whether having preventable factors or not will be cascaded across the neonatal service and referred to the Women’s Clinical Governance Review Meeting, and where relevant, to the Newborn Care Collaborative.

Incident Meetings

These will take place

• weekly at 13:30 Tuesday, Neonatal Unit SCRH
• frequency to be decided, SCBU, St Johns

Quorum attendance will be:

- Two senior nurses

- Two medical consultants

A record of attendance and the cases discussed will be kept. Following this meeting there will be two outcomes:

- Incident closed (+/- following discussion with staff member)

- Escalation to a full investigation (+/- statements required)