Who MC Topic-6
Who MC Topic-6
151
Keywords
Clinical risk, reporting near misses, reporting
errors, risk assessment, incident, incident
monitoring.
Learning objective
4
Know how to apply risk management
principles by identifying, assessing and reporting
hazards and potential risks in the workplace.
152
Sentinel events
8
A sentinel event is an unexpected
occurrence involving death or serious physical or
153
Type of incident
Falls
29
Injuries other than falls (e.g. burns, pressure injuries, physical assault, self-harm)
13
Medication errors (e.g. omission, overdose, underdose, wrong route, wrong medication)
12
Clinical process problems (e.g. wrong diagnosis, inappropriate treatment, poor care)
10
Equipment problems (e.g. unavailable, inappropriate, poor design, misuse, failure, malfunction)
Documentation problems (e.g. inadequate, incorrect, not completed, out of date, unclear)
Logistic problems (e.g. problems with admission, treatment, transport, response to emergency)
Administrative problems (e.g. inadequate supervision, lack of resource, poor management decisions)
Nutrition problems (e.g. fed when fasting, wrong food, food contaminated, problems when ordering)
Colloid or blood product problems (e.g. omission, underdose, overdose, storage problems)
Oxygen problems (e.g. omission, overdose, underdose, premature cessation, failure of supply)
154
Coronial Investigations
Most countries have some system for establishing
cause of death. Specifically appointed people,
often called coroners, are responsible for
investigating deaths in situations where the cause
of death is uncertain, or thought to be due to
unethical or illegal activity. Coroners often have
broader powers than a court of law and after
reporting the facts will make recommendations for
addressing any system-wide problems.
Fitness-to-practise requirements
10
Medical students and all health professionals
are accountable for their actions and conduct in
the clinical environment. They are responsible for
their actions according to the circumstances in
which they find themselves. Related to
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Credentialling
Credentialling is the process of assessing and
conferring approval on a persons suitability to
provide specific consumer/patient care and
treatment services, within defined limits, based on
an individuals licence, education, training,
experience and competence (Australian Council on
Healthcare Standards). Many hospitals have
credentialling processes in place to check whether
a doctor has the required skills and knowledge to
undertake specific procedures or treatments.
Hospitals will restrict the type of procedures offered
at a hospital if there are no qualified personnel or if
the resources are not available or appropriate for
the particular condition or treatment.
Accreditation
Accreditation is a formal process to ensure
delivery of safe, high-quality health care based on
standards and processes devised and developed
by health-care professionals for health-care
services. It can also refer to public recognition of
achievement by a health-care organization of
requirements of national health care standards.
Registration
Most countries require medical practitioners to be
registered with a government authority or under a
government instrument. The principal purpose of
a registration authority is to protect the health and
safety of the public by providing mechanisms
designed to ensure that medical practitioners are
fit to practise medicine. It achieves this by
ensuring that only properly trained doctors are
registered, and that registered doctors maintain
proper standards of conduct and competence.
156
157
Supervision
Good supervision is essential for every student
and the quality of the supervision will determine to
a large extent how successfully a student
integrates and adjusts to the hospital or clinical
environment.
The failure of senior clinicians to supervise or
arrange adequate supervision for medical
students and interns and residents makes
them more vulnerable to making mistakes
either by omission (failing to do something) or
commission (doing the wrong thing).
Students should always request supervision if
it is the first time they are attempting a skill or
procedure on a patient. They should also
advise the patient that they are students and
request their permission to proceed to treat
them or perform the procedure.
Poor interpersonal relationships between
students, other health-care professionals,
interns, residents and supervisors have also
been identified as factors in errors. If a
student is having a problem with a supervisor,
they should seek help from another faculty
member who may be able to meditate or help
the student with techniques to improve the
relationship.
The literature also shows that students who
have problems with inadequate skills
acquisition also have poor supervision. Many
health professionals have learnt a procedure
while unsupervised and were judged by
supervisors to have poor technique and
inadequate mastering of procedures. Students
should never perform a procedure on a patient
without sufficient preparation and supervision.
158
Communication Topics
T4
T8
Communicating accurate information in a
timely way between the multiple health workers
(consultants, registrars, nurses, pharmacists,
radiologists, medical records and laboratory
personnel) is not easy, nor are there standard ways
for communicating within hospitals. The role of
good communication in the provision of quality
health care and the role poor communication plays
in substandard care are both well documented.
How successfully patients are treated will often
depend on informal communications among staff
and their understanding of the workplace [13].
Treatment errors caused by miscommunication,
absent or inadequate communication are well
known and occur daily in hospitals.
The quality of the communication between patients
and other health professionals strongly correlates
with treatment outcomes. Checklists, protocols and
care pathways are effective for communicating
patient care orders.
159
Summary
Teaching strategies/formats
An interactive/didactic lecture
Use the accompanying slides as a guide,
covering the whole topic. The slides can be
PowerPoint or converted to overhead slides for a
projector. Start the session with the case study and
get the students to identify some of the issues
presented in the story.
Panel discussions
Invite a panel of respected clinicians to give a
summary of their efforts to improve patient safety.
Students could also have a list of questions about
adverse event prevention and management and
have time scheduled for their questions. Experts
on risk management outside health care may also
be invited to talk generally about the principles.
160
Simulation exercises
Different scenarios could be developed
about adverse events and the techniques for
minimizing the opportunities for errors such as
practising the techniques of briefings,
debriefings, and assertiveness to improve
communication;
role play using a person approach and then
a system approach in a mortality and
morbidity meetings;
role play a situation in theatre where a
medical student notices something is wrong
and needs to speak up.
Teaching activities
Administration, theatre and ward activities:
students can observe a risk management
meeting;
students could meet with the people who
manage complaints for the hospital or clinic
part of the exercise would be to ask the
hospital policy on complaints and what
usually happens if a complaint is made;
students could take part in an open
disclosure process.
CASE STUDIES
Inadequacy in orthopaedic surgeons
practice management systems
Accurate and legible records are essential for
161
Reference
Open Disclosure. Case StudiesVolume 1.
Sydney: Health Care Complaints Commission,
2003: 1618.
Reference
Patient Support Service, Health Care Complaints
Commission, New South Wales. Annual report
19992000, p. 3746.
An impaired nurse
This case shows how health professionals need to
maintain their fitness to practise.
During Alans operation, a nurse knowingly
replaced the painkiller fentanyl, which was ordered
to treat Alan, with water. This nurse placed Alan in
physical jeopardy because of the nurse's
desperate need to obtain an opiate drug to satisfy
his drug addiction.
Reference
Review of investigation outcomes. Health Care
Complaints Commission, New South Wales.
Annual Report 19981999, p. 3940.
This was not the first time that the nurse had
stolen Schedule 8 drugs for the purposes of selfadministering them. A number of complaints had
been made about the nurse while working at a
162
Reference
Swain D. The difficulties and dangers of drug
prescribing by health practitioners. Health
Investigator, 1998, 1(3):1418.
Reference
Case studiesinvestigations. Health Care
Complaints Commission, New South Wales.
Annual Report 19951996, p. 35.
163
11.
12.
References
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risk management: British Medical Journal
Books, 2001, 914.
2. Barach P, Small S. Reporting and preventing
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near miss reporting systems. British Medical
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3. Runciman B, Merry A, Walton M. Safety and
ethics in health care: a guide to getting it right,
1st ed. Aldershot, UK, Ashgate Publishing
Ltd, 2007.
4. Joint Commission on Accreditation of
Healthcare Organizations. Sentinel event
policy and procedures. In: JCAHO, ed.
Chicago, JCAHO, 1999.
5. Walton M. Why complaining is good for
medicine. Journal of Internal Medicine, 2001,
31(2):7576.
6. Reason JT. Human error: Cambridge,
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deprivation and onerous working hours on the
physical and mental well being of pre-
13.
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