Adverse incidents and near misses
B107
An adverse incident is where harm has occurred, and a near miss is where harm could have occurred.
B108
If an adverse incident occurs you should:
- apologise to the patient
- explain what has happened
- explain any remedial action.
This is what is meant by the duty of candour.
B109
If necessary, you should also:
- investigate the adverse incident
- take the appropriate action
- keep a written record.
B110
You should record any adverse incident somewhere central to the practice, for example in your practice’s system or in the practice Accident Book. This applies even if it was not due to any fault of the practice or practitioner.
B111
If a near miss occurs, you should learn from it and you should reassure the patient if you think it caused them concern.
B112
You should report any near misses or adverse clinical incidents involving patients receiving NHS-funded care:
- in England and Wales to the National Reporting and Learning System (NRLS). This does not collect any patient or practitioner identifiable information210
- in Scotland to your local health board211
- in Northern Ireland to the Northern Ireland Adverse Incident Centre.212
B113
If the adverse incident was due to a drug or medical device you should report this to the Medicines and Healthcare Products Regulatory Agency, as appropriate.213, 214 See sections on Infection control and Use and supply of drugs or medicines in optometric practice.
References
210 Learning from patient safety incidents [Accessed 20 Nov 2020]211 Northern Ireland Adverse Incident Centre (NIAIC). Reporting an adverse incident [Accessed20 Nov 2020]
212 MHRA Yellow Card Scheme [Accessed 19 Nov 2020]
213 Learning from adverse events through reporting and review. A national framework for Scotland: December 2019 [Accessed 22 Sept 2020]
214 MHRA. Report a problem with a medicine or medical device [Accessed 19 Nov 2020]