Management part 3 - Safety and Risk

Blog post retyped as somehow, it converted itself into Greek (ish).


Incident – an untoward or unexpected event including verbal abuse and threats.
Accident – an incident that results in loss or damage like violence.
Clinical Incident – an incident occurring to a patient during or because of treatment.
Clinical Accident – a clinical incident that results in actual harm to the patient
Serious Incidents - where there is potential for learning, or high consequences to patients, families, and staff as so significant that they warrant extra resources to investigate.
Never Event - must be reported. See below.

Should be declared internally as soon as possible. Reports should be completed within 60 days. A root cause analysis should be carried out - there are three levels of this.  
- Concise, comprehensive or independent (which may take 6 months).

 

Negligible
Minor
Moderate
Major
Catastrophic

- Open and transparent
- Preventative
- Objective
- Timely and responsive
- Symptoms based
- Proportionate
- Collaborative

Check patient, and then staff are safe. Obtain and secure all evidence. Offer support to any witnesses. Identify someone to do an initial incident review, and determine level of investigation required. Inform commissioners. Contact family, and support Log on incident management
Serious incidents must be reported to the commissioner within 2 days, sooner if media / public interest.

Retained foreign object post procedure.
Giving strong K+ instead of something else
Parentally administered oral meds OD of insulin due to abbreviations or incorrect device
OD of midazolam due to wrong strength administered
Chest or neck entrapment in bedrails
ABO mismatch transfusion
Misplaced NG or OG tube
Scalding of patients

If it's moderate - severe harm --> report externally to CCG
Never Events must be AId
 - Investigate and always do root cause analysis regardless of harm to patient
 - Reported externally
 - Should be process to stop these happening

https://www.england.nhs.uk/patientsafety/serious-incident/
http://www.npsa.nhs.uk/nrls/improvingpatientsafety/patient-safety-tools-and-guidance/risk-assessment-guides/risk-matrix-for-risk-managers/