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Critical Incidents

Critical Incidents. PRIMARY CARE. AGENCIES. CHI-Commission for Health Improvement NPSA National Patient Safety Agency National Clinical Assessment Authority to name but a few. Why now?. Organisation with a Memory Clinical Governance Risk Management

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Critical Incidents

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  1. Critical Incidents PRIMARY CARE

  2. AGENCIES • CHI-Commission for Health Improvement • NPSA National Patient Safety Agency • National Clinical Assessment Authority to name but a few

  3. Why now? • Organisation with a Memory • Clinical Governance • Risk Management • Supported by the defence organisations

  4. What must we do? • Set up an adverse event reporting system • Define what is to be reported • Ensure staff are trained and supported • Send reports to the PCT

  5. PCT • Must set up adverse event reporting • To Include primary care • To facilitate training in reporting • Collate reports in order to learn from • Events • Report to CHI and NPSA on numbers and themes. • Report serious adverse events to Strategic • HA.

  6. Culture • Airline industry experience • No –blame culture • Learning from events-Root cause analysis • Multidisciplinary and open

  7. YOUR TASK • Reflect on a clinical or organisational • Error which has come to your attention within the last 3 months • Would you report it • How would you report it • Would there be any difficulties • What are the consequences –good and bad…

  8. Homework • Ask your practice manager /ward manager • About critical incident reporting • –where are the forms • -who do they get sent to • How does the practice learn from incidents

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