Developing a departmental culture for reporting adverse incidents.
A simple, reproducible model for reporting adverse events was developed in order to promote cultural awareness and acceptance of risk management within the authors' department. A departmental proforma was created and prospective reporting of adverse events was encouraged. In the six months prior to commencing this study only four adverse incidents were reported. Following the introduction of the proforma 64 critical incidents and near-misses were reported in the one-year period. In conclusion a simple model for reporting critical incidents and near-misses has been established. This has fostered a cultural change within the department and all members of staff feel more comfortable with reporting such incidents. The process is seen as educational and an important part of continuing professional and departmental development. Protocols and changes in organisational practice have been developed to reduce and prevent the occurrence of adverse events and offer patients continuous improvement in care.
Bhatia
R
R
Department of Trauma and Orthopaedics, Royal Gwent Hospital, Newport, Gwent, UK.
Blackshaw
G
G
Rogers
A
A
Grant
A
A
Kulkarni
R
R
D005568:Forms and Records Control; D006302:Health Services Research; D006748:Hospital Departments / Q000458:organization & administration* / Q000706:statistics & numerical data; D006779:Hospitals, Public / Q000458:organization & administration / Q000592:standards; D006801:Humans; D019300:Medical Errors / Q000706:statistics & numerical data*; D008505:Medical Staff, Hospital; D017146:Models, Organizational; D009741:Nursing Staff, Hospital; D015279:Organizational Culture; D016730:Program Development; D012308:Risk Management / Q000458:organization & administration* / Q000706:statistics & numerical data; D006113:United Kingdom