1. Critical Incidents PRIMARY CARE

2. AGENCIES CHI-Commission for Health Improvement CHI-Commission for Health Improvement NPSA National Patient Safety Agency NPSA National Patient Safety Agency National Clinical Assessment Authority National Clinical Assessment Authority to name but a few

3. Why now? Organisation with a Memory Organisation with a Memory Clinical Governance Clinical Governance Risk Management Risk Management Supported by the defence organisations Supported by the defence organisations

4. What must we do? Set up an adverse event reporting system Set up an adverse event reporting system Define what is to be reported Define what is to be reported Ensure staff are trained and supported Ensure staff are trained and supported Send reports to the PCT Send reports to the PCT

5. PCT Must set up adverse event reporting Must set up adverse event reporting To Include primary care To Include primary care To facilitate training in reporting To facilitate training in reporting Collate reports in order to learn from Collate reports in order to learn from Events Events Report to CHI and NPSA on numbers and themes. Report to CHI and NPSA on numbers and themes. Report serious adverse events to Strategic Report serious adverse events to Strategic HA. HA.

6. Culture Airline industry experience Airline industry experience No –blame culture No –blame culture Learning from events-Root cause analysis Learning from events-Root cause analysis Multidisciplinary and open Multidisciplinary and open

7. YOUR TASK Reflect on a clinical or organisational Reflect on a clinical or organisational Error which has come to your attention within the last 3 months Error which has come to your attention within the last 3 months Would you report it Would you report it How would you report it How would you report it Would there be any difficulties Would there be any difficulties What are the consequences –good and bad… What are the consequences –good and bad…

8. Homework Ask your practice manager /ward manager Ask your practice manager /ward manager About critical incident reporting About critical incident reporting –where are the forms –where are the forms -who do they get sent to -who do they get sent to How does the practice learn from incidents How does the practice learn from incidents