1. Risk management September 2000

2. Its all your fault!

3. Risk management Risks to: –Patients –Practitioners –organisations

4. Rather than assigning blame to the unfortunate individuals who find themselves at the sharp end of an error, leaders would take personal responsibility for the safety of the processes and systems in which those individuals work. Our organisations would declare error reduction to be an explicit organisational goal. Reinertsen BMJ 2000;320:730

5. Clinical governance means handling complaints better – for both parties Baker BMJ 1999; 318:1567 - 8

6. Developing learning organisations Celebration of success Absence of complacency Tolerance of mistakes Belief in human potential Recognition of tacit (existing) knowledge Openness Trust Outward looking

7. Significant event audit

8. An event which has the potential to: –Be Examined –Be Learned from –Facilitate change and improvement

9. Critical Events Clinical Administrative

10. Agenda for Significant Event Meetings Review of previous meetings Case presentation

11. Agenda for Significant Event Meetings Review of acute care/immediate problems –Positive –Aspects which could be improved

12. Agenda for Significant Event Meetings Review of possibilities for prevention –Positive –improvements

13. Agenda for Significant Event Meetings Plan of action and follow up –Positive aspects –Aspects needing improvement

14. Agenda for Significant Event Meetings Implications for family / community (if any)

15. Agenda for Significant Event Meetings Team issues

16. Agenda for Significant Event Meetings Summary Recommendations –Should reflect change

17. Agenda for Significant Event Meetings Minutes –Recording is vital