At a time of increasing regulatory scrutiny and medico-legal risk, managing serious clinical incidents within primary care has never been more important. Failure to manage appropriately can have serious consequences both for service organisations and for individuals involved.
This is the first book to provide detailed guidance on how to conduct incident investigations in primary care. The concise guide
- explains how to recognise a serious clinical incident, how to conduct a root cause analysis investigation, and how and when duty of candour applies
- covers the technical aspects of serious incident recognition and report writing
- includes a wealth of practical advice and 'top tips', including how to manage the common pitfalls in writing reports
- offers practical advice as well as some new and innovative tools to help make the RCA process easier to follow
- explores the all-important human factors in clinical incidents in detail, with multiple examples and worked-through cases studies as well as in-depth sample reports and analysis.
This book offers a master class for anyone performing RCA and aiming to demonstrate learning and service improvement in response to serious clinical incidents. It is essential reading for any clinical or governance leads in primary care, including GP practices, 'out-of-hours', urgent care centres, prison health and NHS 111. It also offers valuable insights to any clinician who is in training or working at the coal face who wishes to understand how serious clinical are investigated and managed.
Table of Contents
1 Introduction. 2 What is a clinical incident and what makes an incident serious? 3 Recognising serious incidents. 4 Root cause analysis. 5 Humans and heuristics – why do we make errors? 6 What can we learn? 7 Writing reports. 8 Preventing clinical errors - The Sixth sense and the wisdom of Dr Pepper. 9 Creating a no blame culture - Coroners courts and Litigation. 10 Case studies. 5 cases demonstrating human factors in primary care. When Humans and systems interact.
Dr Russell Kelsey is Regional Medical Director of North and West, Health Care Division, Care UK, the largest independent provider of NHS care in the UK. His role encompasses clinical governance for provision of out of hours and NHS 111 services to a region with a patient population of over 5 million. He is also Care UK Subject Matter Expert in Serious Clinical Incident investigation and provides CPD accredited training in SI recognition and RCA for both internal Care UK staff as well as for NHS colleagues from outside the organisation Russell has received training from both NPSA and NCAS in case management and is NPSA trained as a
"This is a well organised, well written, and absorbing book offers a real masterclass for anyone performing Root Analysis and aiming to demonstrate learning and service improvement in response to serious clinical incidents. It should be essential reading for any clinical or governance leads in primary care, including GP practices, out-of-hours, urgent care centres, prison health and NHS 111."
Jacky Steemson, OS&H Journal, July 2017