Risk management

September 2000

It’s all your fault!

Risk management

• Risks to:– Patients– Practitioners– organisations

“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

“Clinical governance means handling complaints better – for

both parties”

Baker BMJ 1999; 318:1567 - 8

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

Significant event audit

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

Critical Events

• Clinical

• Administrative

Agenda for Significant Event Meetings

• Review of previous meetings

• Case presentation

Agenda for Significant Event Meetings

• Review of acute care/immediate problems– Positive– Aspects which could be improved

Agenda for Significant Event Meetings

• Review of possibilities for prevention– Positive– improvements

Agenda for Significant Event Meetings

• Plan of action and follow up– Positive aspects– Aspects needing improvement

Agenda for Significant Event Meetings

• Implications for family / community (if any)

Agenda for Significant Event Meetings

• Team issues

Agenda for Significant Event Meetings

• Summary

• Recommendations– Should reflect change

Agenda for Significant Event Meetings

• Minutes– Recording is vital