Our incident panels meet weekly to review orange and red Datix incidents, and if a patient has been harmed by an action of the team caring for them, the incidents are further investigated and validated. Our message this week is to always check with a colleague or manager before reporting orange or red incidents.
Recently our panels have seen a larger number than usual of incidents, which after review by the panel have been downgraded to yellow (minor harm) or green (no harm).
If you are reporting an orange or red incident on Datix please discuss with your line manager or another colleague whether they agree with your thoughts BEFORE submitting it.
Examples of orange incidents that have recently been downgraded:
- A patient suffered an allergic reaction (anaphylaxis) to an anaesthetic drug. This would be orange if we had known the patient was allergic, though in this instance it was not a known allergy, and the anaphalaxis was managed appropriately. This was downgraded to yellow
- A patient presented in A&E following a fall at home. An x-ray was taken but nothing showed as broken. The patient went home but after a few weeks was still having difficulty weight bearing and complained of groin pain. Patient presented back in A&E and a second x-ray showed a fractured pubic rami. There was nothing we could have done differently. This was downgraded to yellow
- A patient was discharged to a nursing home without their insulin. This was reported as orange and the Safeguarding Team became involved. However, once the paramedics realised they hadn’t picked up the insulin they contacted the hospital and the hospital took the insulin to the care home. The incident was downgraded to green because the patient was without their insulin for less than two hours and didn’t miss any doses.
In summary: Ask a manager or colleague for their opinion BEFORE logging orange and red incidents.
If you have any questions please contact the Risk Team on Huddersfield 2024.