Endoscope decontamination incidents report (PDF, 164K, 20secs)
About this Report
In January 2006, NHS QIS disseminated copies of ‘Safe Today – Safer Tomorrow: Review of Incident and Near-Miss Reporting’. The outcomes from this piece of work resulted in a number of practical recommendations on how to improve and develop effective systems to support the identification and resolution of safety problems. The NHS QIS action plan in response to this work was produced and disseminated in July 2006.
To take forward implementation of this action plan, NHS QIS established the Safe Today- Safer Tomorrow Action Plan Steering Group, and subsequently four specific working groups to focus on particular areas of the action plan. One of these working groups was tasked with focussing on healthcare associated infections and, in particular, endoscope decontamination incidents.
The working group accepted from the direct experience of its members that adverse incidents involving any aspect of decontamination of endoscopes are likely to be significantly under-reported at both local and national levels.
A short pilot was undertaken to increase reporting of endoscope decontamination related incidents. This was achieved through the development of a tailored dataset for endoscope decontamination incidents, piloted in three NHS Boards, making use of established incident reporting mechanisms in each test site Board. During the project, the pilot NHS Boards were advised to continue to report relevant incidents and near misses to Health Protection Scotland through the usual channels.
This report provides a summary of the work of the working group, the outcomes from the evaluation of the data collected, and the findings and recommendations from this project.
