Managing a clinical incident

˚Phones off

˚Pager free time ( if possible)

˚Confidentiality

Objectives

• To describe the processes involved in clinical incident management

• To discuss the importance of clinical incident reporting in improving patient safety

• To discuss coping strategies after being involved in an adverse event

Outcome Definitions

•Clinical incident: An event or circumstance which could have or did harm a patient

•Near miss: An incident which did not reach a patient

•No-harm incident: An incident which reached the patient but did not cause harm

•Adverse event: An incident that harmed a patient

Clinical incidents = Near misses (90%) + Adverse events (10%)

Summary of Module 1

• Errors are inevitable

• When errors happen in the clinical environment the consequences can be devastating

• Always consider circumstances when errors might occur and think of ways to minimise the errors and their effects…

Faultlines Videopart 2

Click to view video.Do not interrupt video once started.Let video run through its entirety.

Adverse events happen

• Think about an incident you were involved in

• What happened?

• What was the error?

• What happened next?

Think more about the facts, not how it felt. We will be dealing with the feelings and emotions later in the session

What should happen after an adverse event?

1. Assessment & treatment of patient to minimise harm

2. Open disclosure

3. Identification & notification of the adverse event

4. Review of circumstances & contributing factors

Patient safety & satisfaction: dealing with mistakes and complaints, Merrilyn Walton 2007

Open disclosure = open communication

Open Disclosure refers to open communication when things go wrong in health care and include:

1. An expression of regret;

2. A factual explanation of what

happened;

3. Consequences of the event; and

4. Steps being taken to manage the

event and prevent a recurrence.

Australian Commission on Safety and Quality in Healthcare. Open disclosure standard. Canberra: Commonwealth of Australia, 2003

Reporting

Results from a recent Australian study show when given a hypothetical situation involving clinical incidents:

90% of interns said they wouldn’t report

Junior Medical Officers and Medical Error PMIT 2007

Why doctors may not report

• Feelings of shame or guilt• Fear of punishment/ retribution• Membership of profession that values perfection• System factors• Inadequate or no feedback• Time constraints• Lack of confidentiality• Failure to respect or have faith in process• Lack of knowledge on how to report

˚

Junior Medical Officers and Medical Error. PMIT 2007

Why doctors may not report

I don’t like to fill in an incident report – it seems a lot of effort, for no outcome”

“There doesn’t seem to be a point in writing an incident form because you never get any feedback..”

“I don’t know the process of what happens after the reporting of an error- I don’t want to get someone into trouble”

Junior Medical Officers 2007

Why doctors may not report

“I don’t have any faith in ‘no blame’ policies – I think when it comes down to it, you would be alone”

“I want to know if I have made a mistake, to address it and to improve – to continuously improve…… but it doesn’t happen”

“It’s frightening not knowing what’s going to happen if I report an error, and what it means to me. Am I going to get into trouble?”

Junior Medical Officers 2007

How does incident reporting lead to improved patient safety?

Clinical I ncident

RecogniseI ncident

Notif y I ncident

I ncident

Analysis

Local Corrective

Actions

System wide

corrective actions

PATI ENT EXPERI ENCE

Safety Improvement Cycle - Source - Second Report into Clinical Incidents in Queensland – Patient Safety: From Learning to Action II (2008). Available at http://www.health.qld.gov.au/patientsafety/documents/learn2.pdf

Why report?

Introduction of changes reduce adverse events by 50 – 75%

• Changes to local protocols• Audits• Worksheets & supervised practice• Feedback & discussion• Checklists

How to report

What happens after an adverse event is reported

to be inserted here:

Steps showing what happens when a report is received

@ local hospital

“Adverse events: the second victim”

• If you were involved, how did you feel?

• If it wasn’t you, how do you think the doctor felt?

Feelings/reactions

In response to their mistakes doctors said the support they needed was

•63% someone to talk to•59% reaffirmation of their

professional competency•48% validation in their decision

making process•30% reassurance of self worth

The emotional impact of mistakes on family physicians. Newman MC 1996

Coping strategies

• Talking• Learning /changing• Taking action• Physical activity/distraction• Seeking support• (Alcohol/other drug use)• (Withdrawal/denial)

Adapted from Residents responses to medical error: coping, learning, and change.

Engel et al 2006

Where to go for support

• Registrar/Consultant

• Medical Education Officer

• Director of Clinical Training

• Medico Legal Advisor

• Employee assistance program

Any questions?

Summary

• Clinical incidents are underreported by doctors

• Reporting clinical incidents improves patient safety

• You should now be aware of your local incidentreporting processes

• You should now be aware of successful copingstrategies after experiencing an adverse event