When something goes wrong.
WHAT INCIDENTS INCLUDE
Harm to a patient Near misses Medication errors Equipment failure Wrong patient or wrong procedure Infection transmission
WHY NEAR MISSES MATTER
They reveal the failure before it harms anyone.
WHAT TO ESTABLISH
A reporting system, and the expectation that everything is reported.
WHAT MAKES REPORTING FAIL
Blame.
WHY
Staff conceal what they will be punished for, and the cause is never addressed.
WHAT TO ASK WHEN AN INCIDENT OCCURS
What happened What allowed it What would have prevented it
WHAT NOT TO ASK FIRST
Who did it.
WHAT TO DISTINGUISH
Error from deliberate disregard.
WHY
Conflating them destroys the reporting culture.
WHAT TO DO IMMEDIATELY
Address the patient's needs Inform whoever is responsible Preserve evidence, including equipment and records
WHAT TO DO ABOUT THE PATIENT
Tell them what happened, honestly.
WHY
Concealment compounds the harm and it is discovered.
WHAT TO RECORD
Factually, contemporaneously, without speculation.
WHAT TO NEVER DO
Alter records after an incident.
WHY
It transforms a defensible event into an indefensible one.
WHAT TO DO AFTERWARDS
Establish the cause and change what allowed it.
WHAT TO TRACK
Incidents by type, over time.
WHAT TO TAKE ADVICE ON
Anything involving serious harm.
