1. Managing a clinical incident

2. ˚Pager free time ( if possible) ˚Confidentiality
˚Phones off
˚Pager free time ( if possible)
˚Confidentiality
Action
It is important to emphasise that this is a ‘protected’ environment. Participants should be assured that whatever they disclose will not leave the room, unless the issue that they raise poses an ongoing threat to patient safety. In this case, the presenter has a professional duty to report the problem, but can de-identify the participant who raised it.

3. 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

4. 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%)
This slide can be omitted if the definitions have previously been discussed in Module 1.

5. 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 Video
part 2
Click to view video.
Do not interrupt video once started.
Let video run through its entirety.

6. If this module is being delivered separately to module 1 (ie on a different day), this short clip from the faultlines video can be used to set the scene: an adverse event has occurred and we are now going to discuss what happens next. If this module runs immediately after module 1, there is no need for this clip to be shown as the video will be fresh in everyone’s mind.

7. 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
Action
Within small groups if possible
ask to consider & discuss above; then as a large group, open discussion.
If the participants are struggling to provide examples, remind them that it needn’t be a serious adverse event which caused harm. It may be a near miss that they observed or where involved in, which may be easier for them to disclose.

8. What should happen after an adverse event?
Assessment & treatment of patient to minimise harm
Open disclosure
Identification & notification of the adverse event
Review of circumstances & contributing factors
Patient safety & satisfaction: dealing with mistakes and complaints, Merrilyn Walton 2007
It encourages participation if only the title is shown, and the participants are asked what they think should happen. The ‘answers’ can be introduced via mouse click. It can be interesting to ask them to contrast the recommendations on the slide with what actually happened in the events that they witnessed.

9. 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
Open disclosure is all about:
˚ Encouraging open & effective communication by staff with patients
˚ Acknowledging that adverse events occur
˚ Saying sorry to patients for any harm suffered during their care
˚ Being there for your colleagues if they're involved in an adverse event
˚ Changing the culture from blame to improvement
˚ Making our health system safer
There now exists Open Disclosure National Standards.

10. 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
Action
Before introducing the text, ask: What percentage of junior doctors do you think would report a medical error they witnessed?

11. 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
Again, it’s helpful to gain their views before displaying the ‘answers’. It’s impressive how consistent their replies are with what is presented on the slide.

12. 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

13. 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

14. How does incident reporting lead to improved patient safety?
Safety Improvement Cycle - Source - Second Report into Clinical Incidents in Queensland – Patient Safety: From Learning to Action II (2008). Available at
This simple diagram shows how information from clinical incidents and adverse events is used to improve patient safety.
Junior doctors should be encouraged to explore each step in their own workplace and identify weaknesses and particularly how they can contribute to this. They often get stuck on incident reporting systems – takes to long; not enough computers etc. Suggest explore with them whether reporting is good thing. If so, then question is how they can do this. There are many ways to report and sometimes, a discussion with a local safety officer or ward based paper system can work really well for docs. Relies upon the leadership which will also be afactor for discussion. Ie what to do if your boss doesn’t want to hear about or address problems/incidents.

15. Why report? Introduction of changes reduce adverse events by 50 – 75%
Changes to local protocols
Audits
Worksheets & supervised practice
Feedback & discussion
Checklists
It is helpful if you have a ‘local story’ of an incident report which led to action and subsequent improvement in care.

16. See accompanying presenters guide
For this slide, just give a brief overview of the case

17. The highlighted text emphasises that there was clearly an error in some aspect of the reporting system. This particular adverse event had occurred frequently before this highly publicised case, and unfortunately has continued to be reported since this case (including two cases in Australia in the last couple of years).

18. How to report
You should insert your own local reporting system in here. Do not spend too long on this, as it will almost certainly be covered in a stand-alone session. This is merely a reminder

20. What happens after an adverse event is reported
to be inserted here:
Steps showing what happens when a report is received
@ local hospital
This was one of the issues that clearly came out of the previous medical error project: JMOs want to know in some detail exactly what happens if they complete an incident report.

21. “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?
Action
Discuss in small groups
Alternative
If time does not allow discuss as large group
Ask: think back to the beginning of the session when I asked you to think about an adverse event or near miss that you had experienced or witnessed,
Now think about how did you feel….as above

22. For this slide, again just give a brief overview of the case (see clinician presenter’s guide).

24. The highlighted text emphasises the initial response of relatives of victims of adverse events. It contrasts nicely with the next slide.

25. The highlighted text emphasises the personal effects suffered by doctors involved in serious adverse events. This inquest was almost a year after the event and the doctor is obviously still severely distressed.
The second highlighted text illustrates how relatives are, on the whole, very forgiving about adverse events, as long as they believe that their concerns have been addressed and that there is genuine honesty on the part of those staff involved.

26. 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

27. 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
The bottom two points are in brackets as they are clearly not healthy reactions (although they are very understandable and unfortunately very common)

28. Where to go for support Registrar/Consultant Medical Education Officer
Director of Clinical Training
Medico Legal Advisor
Employee assistance program
This slide should be modified according to local protocols.

29. Any questions?

30. Summary Clinical incidents are underreported by doctors
Reporting clinical incidents improves patient safety
You should now be aware of your local incident
reporting processes
You should now be aware of successful coping
strategies after experiencing an adverse event
Action
Ask participants to complete a workshop evaluation before leaving
Handouts
List of resources