Supporting a safety culture

Supporting a safety culture

Adverse events and near misses go unreported for many reasons, including a fear of blame and the potential for litiga - - tion. Clinical risk management is an integrated process, based on risk identification, analysis and control of events, carried out within a ‘blame-free’ environment. Data collected from these episodes should be collated and learnt both institutionally and by uploading to a national database. Doctors should be familiar with the systems that operate within their own working environment. Complaints from a patient or carer often highlight a prob - lem that, when analysed, provides opportunities for reduc - ing adverse events. Knowing how to manage complaints is an important part of providing better health care. There is wide acceptance for the need for complaints to be made easily and e ff ectively , such that now more and more pa tient advo - cacy units provide a range of options for resolving complaints, - including the provision of information and mediation and the setting up of conciliation meetings between the parties. Such risk management is complex and involves multiple domains , including operational, legal and financial issues. For the pur - - pose of this chapter the focus is on clinical risk, benchmarking - and incident reporting. Most medical care entails some level of risk to the patient, either from the underlying condition or comorbidity or from the treatment itself, each of whic h may lead to recognised com - plications or side e ff ects. These episodes m ust be di ff erentiated from patient safety incidents, which have been described as - prev entable events or circumstances that did or could result in unnecessary harm to a patient. These include adverse events that result in actual harm, near-miss events that by chance or intervention cause no harm and no-harm events that reach olve - a patient but result in no harm because of chance or other - mitigating circumstance. The most frequent contributing factors that lead to patient safety incidents are listed in Table 15.1 . Of these, inadequate - communication between healthcare sta ff , or between medical sta ff and their patients or family members, ranks highest in frequency .