When the Swiss cheese aligns - Making a clinical error Workshop When the Swiss cheese aligns - Making a clinical error

Learning objectives Identify and appraise both common clinical factors and human factors that can lead to medical error or that put patient safety at risk Indicate what key non technical skills can be employed to prevent medical errors Describe how to appropriately communicate, and also the actions required, when discussing a mistake with a patient, relative or staff member Apply knowledge of common blood transfusion reactions to respond appropriately to potential reactions.

Will this go on my record?

What were the key factors which led to the mistake being made? Split into groups Clinical factors Non clinical factor What was done well as a result of the mistake What could have been improved in response to the error

Every healthcare professional must be open and honest with patients when something that goes wrong with their treatment or care causes, or has the potential to cause, harm or distress. This means that healthcare professionals must: Tell the patient (or, where appropriate, the patient’s advocate, carer or family) when something has gone wrong Apologise to the patient (or, where appropriate, the patient’s advocate, carer or family) Offer an appropriate remedy or support to put matters right (if possible) Explain fully to the patient (or, where appropriate, the patient’s advocate, carer or family) the short and long term effects of what has happened.

Have a go at explaining a clinical error to a relative e.g. 1 FY1, 1 Relative and 1 observer

Clinical error scenarios For each scenario: Explain the importance or impact on patient safety How would you deal with the scenario? What action would need to be taken? Who needs to be informed? How they would confirm appropriate action has been taken?

Incident Reporting Cycle Incident Occurs Take immediate actions Inform person in charge Take further immediate action Complete an incident form Incident review and approval by Manager Classification and grading of incident Inclusion of incidents into trust reporting system

Example Incident form

Questions and summary Thank you