Procedure not followed - PDF document

1 Procedure not followed N. Hazelhoff
Procedure not followed N. Hazelhoff Roelfzema , PhD student Edinburgh Napier University , June 2012 Page 1 Scenario: Procedure not followed The experts estimate d the possible frequency of occurrence similar to the frequency of past incidents (40 out of 1000). The range of expert estimations did not decrease much in round 2 from a range of 99 to 95. Half of the experts in the panel estimate the frequency to lie between 10 and 50 times per 1,000 incidents. Round 2 showed outliers with higher estimations and lower estimations. Most of the comments made by the experts refer to staff often breaching policy and proced ures but this is not always reported as an incident. Expert’s agreement on frequency of this scenario: Round 1 Round 2 5 per 1,000 25 % 10 % 5 - 10 per 1,000 17 % 10 % 10 - 50 per 1,000 17 % 50 % 50 - 100 per 1,000 42 % 30 % �100 per 1,000 0 % 0 % Estimations per expert : Expert Round 1 Round 2 Out of 1,000 this will ID12 100 40 happen: ID13 75 5 ID14 50 60 ID15 8 25 ID17 10 - ID18 30 30 ID19 3 100 ID20 100 - ID22 75 20 ID23 1 10 ID24 5 40 ID25 75 100 Procedure not followed N. Haz

2 elhoff Roelfzema , PhD student Edinburgh
elhoff Roelfzema , PhD student Edinburgh Napier University , June 2012 Page 2 Descr iptive statistics and frequency distribution : Scenario details: Initiator Internal employee Motive No motive, unintentional action Location On the premises Meth od Unknown Vulnerability Procedure not followed Event Confidentiality breach: disclose personal data Costs Unknown Causing Compliance to regulation affected Embarrassment to the organisation or medical staff Affecting 10 patient records Round 1 Round 2 Median 40 35 Range 99 95 Highest 100 100 Lowest 1 5 Mean 44.3 43 St Dev 39.27 33.93 Procedure not followed N. Hazelhoff Roelfzema , PhD student Edinburgh Napier University , June 2012 Page 3 Expert’ s comments : Expert ID R ound Comments ID12 R1 Ignorance or seeing rules as 'getting in the way' will always ensure that this is a high risk. It can only be countered by good security awareness training programs. R2 Most likely to occur with paper reco rds, especially if left in patient private rooms (i.e. they are often left there if the patient is not in a multi - occupancy ward). ID13 R1 T o o often patient data handling urgency overrules the safe conduct; else staff is n

3 ot aware of any policies (unskille d or
ot aware of any policies (unskille d or low skilled staff) or does not have any interest (high or extremely specialized skilled staff)... R2 Don't have any of these incidents ID14 R1 Maybe more common since leaving documents in an office is common whilst on break etc. Not really seen as an incident by staff concerned as patients often not in the admin areas. In clinical areas different matter as patients often could be near paper or electronic based records and could see other individual’s records. May be more frequent due to lack of repo rting or patient complaints. R2 Fairly common scenario particularly with busy staff leaving for break from admin or reception areas. Staff wouldn’t perceive themselves to be breaking the rules and hence may happen more often than is reported thus the abo ve mean estimate of risk. ID15 R1 It all depends on user awareness, training, sanctions, and perhaps the motivation for intentional disclosure. ID17 R1 Procedures are normally followed precisely within medical environments. R2 Procedural issues are the most common; any one will any time escape the formal approach. ID18 R1 Not following procedures happens regularly. We tend to be helpful, fix problems outside of procedures. Procedures contain checks to contain and correct this behaviour

4 . We are increasi ngly getting better a
. We are increasi ngly getting better at this - hence the number of instances should decrease. R2 We specify more and better procedures covering more work activities. Procedures contain checks, so they are increasingly more fault - resistant. As staff finds that following p rocedures leads to better results, adoption rate increases. All leading to better results than in the past. ID19 R1 I don't know how many, but this occurs once in a while. Procedure not followed N. Hazelhoff Roelfzema , PhD student Edinburgh Napier University , June 2012 Page 4 R2 Procedural issues are the most common; any one will any time escape the formal approach. ID20 R1 This is dealt with as a disciplinary matter as all new employees are trained including all new clinical staff. Usually. Failure to follow procedure increases risk but does not lead to disclosure outside the NHS. The most common failure to follow procedure links to staff not placing confidential material in lockable, traceable, tamper - proof bags. ID22 R2 From experience those organisations with robust early induction with very clear policies regarding IG outlined to staff at these induct ion session have seen less incidents, these need to be scenario based so the staff can relate to them and with regular updates and awareness briefi