ISB2502 – Delayed emergency access due to faulty en suite WC door lock

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DL1 NHS Incidents and alerts Safety Officers

DL2 Local Authority Incidents and alerts Safety Officers

For information

DL3 Specialist Liaison Group

DL4 Product Specialists

DL5 General list (internal)

DL7 General list (external)

IMPORTANT

This safety bulletin is intended to share feedback from our national adverse incident reporting, learning and prevention system.  It is designed as an easy to follow, bite-size summary of what happened, what was learned and how the same thing can be prevented from happening again.  

Do please share the flashcard with relevant professional leads and department heads. It can also be shared with networks and comms channels. By doing so, we hope to not only reduce the likelihood of this specific issue recurring, but also to raise the profile of feedback from incident reporting, learning and prevention systems. It is hoped this will encourage more adverse incident reporting both locally in your area and nationally to IRIC. 

Hyperlinks are included at the bottom of the flashcard so you have instant access to our incident reporting and safety alerts webpages. QR codes are also included for those with a mobile device who are viewing the flashcard on a TV screen or a printed version in a staff room for example.

In the meantime please don’t hesitate to get in touch if you’d like to raise a suggestion or a request for subject matter you’d like to see addressed in future IRIC Safety Bulletins.

Onward distributionAs the nominated person for your organisation you need to forward this information to managers and staff in your organisation who need to know or be aware of it.

Adverse Incidents

Incidents and near-misses should always be reported to local incident management systems (often referred to as Datix, Ullyses, SHE, etc.). However, IRIC also needs to be informed about incidents and near-misses when they involve:

• Medical devices (e.g. infusion pump, central line, hoist, care bed, x-ray machine, ventilator)
• In vitro diagnostic devices or IVDs (e.g. blood analyser, reagent, SARS-CoV-2 test kit)
• Estates and facilities (e.g. electrical installations, window restrictors, nurse call systems)
• Social care equipment (e.g. mobile wheeled commode, powered rise and recline chair)
• Personal protective equipment or PPE (e.g. visors, FFP3 respirators, aprons)

We need incident reports so we can work with manufacturers and our partners to stop the same thing happening again. Health and care professionals can also report safety concerns about equipment and devices when an incident or near-miss has yet to occur. Information about how to report an incident to IRIC can be found here: https://www.nss.nhs.scot/health-facilities/incidents-and-alerts/report-an-incident/.   

Enquiries
If you received this alert directly from IRIC, email us at nss.iric@nhs.scot or phone0131 275 7575 quoting the alert reference number.Alternatively, if you have received this message from someone in your own organisation, please direct all enquiries to them and they will liaise with IRIC as required.

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​Incident Reporting & Investigation Centre (IRIC)

NHSScotland Assure

NHS National Services Scotland

Tel: 0131 275 7575 | Email: nss.iric@nhs.scot 

IRIC operates incident learning and prevention systems for health and care technologies (medical devices, IVDs, estates, facilities, social care equipment and PPE). Visit our website to report an incident and find our safety alerts.

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We are NHS National Services Scotland. We offer a wide range of services and together we provide national solutions to improve the health and wellbeing of the people of Scotland. Find out more in our NSS Strategic Framework 2024-2026

FAC406-310, 8B(v), Rev 1

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