Contract Junior doctor England

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Exception reporting - Safety concerns

Exception reporting for missed training opportunities

Safeguarding training and ensuring safe working is of equal and vital importance to trainees and their patients. All instances where variation occurs to training or working patterns from that agreed in the work schedule should be exception reported.

If an issue does not fit neatly under a training or a safe working category, you should copy the report to both the guardian of safe working and the director of medical education so that compensatory measures, improvements to training, and a work schedule review can be actioned, where required.


Patient safety needs

There are circumstances where you may consider yourself to have a professional duty to stay behind and ensure patient safety. Ideally, you would be able to obtain authorisation for this beforehand, but you should submit an exception report afterwards if this isn’t possible.

Remember that prior authorisation is never required for exception reporting.

There are a range of activities that could constitute the need to ensure patient safety, such as

  • stabilising acutely unwell patients
  • ensuring safe handover
  • taking blood tests
  • discussing patient care with relatives
  • making urgent referrals
  • checking and reviewing test results.

These are all issues that are vital for ensuring patient safety and should be built into the work schedule. If you are concerned that your work schedule does not provide sufficient time for such activities and you find yourself filing regular exception reports for working additional hours, you should request a work schedule review to address this.

Please note that where you have concerns regarding and immediate and substantive risk to either your or a patient’s safety, you should refer to the below section on ‘immediate safety concerns.’


Example scenario

Sarah is an ST3 in Emergency Medicine who is rostered to finish at 1am on Friday. She finds herself having to stay behind until 2am in order to ensure safe handover. Sarah files an exception report and agrees TOIL for the additional hour worked. This happens again the next Friday, and another two Fridays the following month. Sarah files exception reports every time, agreeing either TOIL or pay each time depending on her rest needs and those of the service.

The guardian monitors these exception reports and notices a pattern. The guardian schedules a work schedule review to address this. In the review, Sarah and her educational supervisor agree that Sarah often needs to leave at 2am in order to ensure safe handover due to service needs. Taking into account staffing levels, they agree that Sarah should be rostered to finish work at 2am for the rest of her placement. Her work schedule and salary are adjusted accordingly.

This information on staff levels informs the guardian’s quarterly and annual reports, and is shared with the LNC and the Board.


Immediate safety concerns

There may be circumstances where you have a concern regarding an immediate and substantive risk to your own or a patient’s safety. This will likely be regarding your own fitness to work, for example due to fatigue, but not always.

Where possible, any concerns you have surrounding an immediate substantive risk to either your own or a patient’s safety should be raised immediately in conversation with the clinician responsible for the service, such as the on-call consultant, or the patient’s consultant.

You should also send an exception report to the educational supervisor with the guardian copied in within 24 hours. It is then the responsibility of the clinician to respond as follows:

  • If they agree that there is an immediate risk, you will be given immediate time off or provided with immediate support (depending on the nature of the issue). The clinician must also notify the educational supervisor and guardian within 24 hours – the educational supervisor will then carry out an immediate work schedule review and ensure corrective action is taken.
  • If the clinician believes the concerns are serious but not immediate, they should ask you to submit an exception report and request a work schedule review.
  • If the clinician believes the concern is significant but not serious, or that similar concerns are raised regularly, they should ask you to submit an exception report within 24 hours.

You should remember to copy the guardian in all exception reports arising from such concerns. If it is not possible to raise concerns verbally with the clinician, you should still file an exception report as soon as practicably possible.


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