Transcript SEAs Sept 05

Significant Events
Shirley Moon
Clinical Governance Facilitator
14th September 2005
NPSA – Reported incident types
in general practice
INCIDENT TYPE
NUMBER
%
Patient accident
27
6.2
Medication
91
20.8
Documentation (including records, identification)
104
23.7
Consent, communication, confidentiality
70
16.0
Access, admission, transfer, discharge
44
10.0
Clinical assessment (including diagnosis, scans, tests)
40
9.1
Infrastructure (including staffing, facilities, environment)
12
2.7
Medical device/equipment
7
1.6
Treatment, procedure
12
2.7
Implementation of care and ongoing monitoring/review
5
1.1
Disruptive, aggressive behaviour
2
0.5
Infection control
1
0.2
Patient abuse (by staff/third party)
2
0.5
Other
21
4.8
TOTAL
438
100.0
PCT Incident Database
 54 Medication errors, including 18 incorrect drug
and 11 incorrect dose. (Reported by GPs,
Pharmacists and Hospital Pharmacy.)
Need to double check prescriptions.
 13 Documentation errors and 77 Communication
incidents, including 29 between healthcare staff
(e.g. messages not passed on, lack of
communication between primary/secondary care)
and 22 between staff and patients (e.g. patients
getting wrong results).
Need to check Admin procedures.
 2 educational needs highlighted (JK progressing) –
re: X-ray procedures and spinal cord compression.
NPSA - Anticoagulants
 The National Reporting and Learning System
database includes 311 incidents involving
anticoagulants, including 2 deaths.
 600 negligence claims as a result of harm or
near harm associated with the use of
anticoagulants. 120 cases resulted in death.
 223 cases reported to the MDU, including 60
deaths reported from general practice.
 Main causes for fatal incidents were
inadequate laboratory monitoring and
clinically significant drug interactions usually
involving pain killers.
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