A guide to manage clinical risks, errors, near-misses and adverse events
This guide has been developed to help GPs and their practice teams manage clinical risks, errors, near-misses and adverse events effectively and efficiently.
The guide content maps to the RACGP Curriculum Statement on Quality and Safety, which forms part of The RACGP curriculum for Australian general practice and should serve as a starting point for further exploration of this topic.
It starts by outlining different threats to patient safety, then explores human factors that can increase or decrease the risk of patient safety incidents. These include absentmindedness, present-mindedness and error-wise practice.
It then looks at human factors within a clinical context to understand their complex interaction with other factors (such as clinical technologies, infrastructure, systems and processes) and how this can influence the occurrence of patient safety incidents. Some theories of how incidents evolve are presented next.
This sets the scene for the central theme in Section 5: A 10-step systems approach to patient safety. This marks a significant turning point in the history of risk and incident management, which previously centred on human error and individual blame. The systems approach to patient safety involves creating a supportive, open and inclusive organisational culture, where clinical risks and incidents can be skilfully discussed, investigated and strategically managed to appropriately address the impacts and prevent recurrences. Following implementation of practice-based solutions and safeguards, it is important to evaluate what did or did not work. This gives practice teams the opportunity to learn from their experiences.
The guide closes with a detailed look at the critically important medico-legal implications associated with clinical risks and incidents.
Aim
This resource aims to increase general practice teams’ understanding of clinical risks and how they can be managed through a systems approach to patient safety.
This involves:
- creating a just and open organisational culture
- understanding the human and contextual determinants of safety
- supporting skilful identification and investigation of patient safety issues
- implementing safeguards to prevent recurrence
- ongoing patient safety monitoring.
It also gives practice teams the opportunity to develop an understanding of their medico-legal responsibilities and the risks associated with lapses in patient safety.