Critical IncidentsCritical Incidents

PRIMARY CAREPRIMARY CARE

AGENCIESAGENCIES

• CHI-Commission for Health CHI-Commission for Health ImprovementImprovement

• NPSA National Patient Safety AgencyNPSA National Patient Safety Agency

• National Clinical Assessment AuthorityNational Clinical Assessment Authority

to name but a fewto name but a few

Why now?Why now?

• Organisation with a MemoryOrganisation with a Memory

• Clinical GovernanceClinical Governance

• Risk ManagementRisk Management

• Supported by the defence organisationsSupported by the defence organisations

What must we do?What must we do?

• Set up an adverse event reporting systemSet up an adverse event reporting system

• Define what is to be reportedDefine what is to be reported

• Ensure staff are trained and supported Ensure staff are trained and supported

• Send reports to the PCTSend reports to the PCT

PCTPCT

• Must set up adverse event reportingMust set up adverse event reporting• To Include primary careTo Include primary care• To facilitate training in reporting To facilitate training in reporting • Collate reports in order to learn from Collate reports in order to learn from • EventsEvents• Report to CHI and NPSA on numbers and Report to CHI and NPSA on numbers and

themes.themes.• Report serious adverse events to Strategic Report serious adverse events to Strategic • HA.HA.

CultureCulture

• Airline industry experienceAirline industry experience

• No –blame cultureNo –blame culture

• Learning from events-Root cause analysisLearning from events-Root cause analysis

• Multidisciplinary and open Multidisciplinary and open

YOUR TASKYOUR TASK

• Reflect on a clinical or organisationalReflect on a clinical or organisational

• Error which has come to your attention Error which has come to your attention within the last 3 monthswithin the last 3 months

• Would you report itWould you report it

• How would you report it How would you report it

• Would there be any difficultiesWould there be any difficulties

• What are the consequences –good and bad…What are the consequences –good and bad…

HomeworkHomework

• Ask your practice manager /ward Ask your practice manager /ward managermanager

• About critical incident reporting About critical incident reporting

• ––where are the forms where are the forms

• -who do they get sent to-who do they get sent to

• How does the practice learn from How does the practice learn from incidentsincidents