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

2. 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.

3. Will this go on my record?

4. 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

5. 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.

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

7. 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?

8. 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

9. Example Incident form

10. Questions and summary
Thank you