Significant Care Analysis

Question 1

Key features of significant analysis?

Answer 1

1. Describe the incident/event that occurred.
2. Consequences of the incident to all people involved?
3. Cause/s of the incident
4. Prevention from occurring again?

Question 2

How should an adverse event be communicated?

Answer 2

the communication of adverse events should be done in a gentle, non-rushed manner in a private setting
- Formulate a plan of communication prior to approaching the patient and/or family

Question 3

After an adverse event what do patients expect for you to communicate?

Answer 3

Studies show that after an adverse outcome, patients expect and want timely and full disclosure of the event, an acknowledgment of responsibility, an understanding of what happened, expressions of sympathy, and a discussion of what is being done to prevent recurrence.

Question 4

Consequences to the patient or family after an adverse event?

Answer 4

1. Grief
2. Confusion
3. Blame
4. Anger
5. Fear

Question 5

Consequences to you and all members of the team after an adverse event?

Answer 5

1. Guilt
2. Blame
3. Discouragement
4. Feeling Overwhelmed
5. Fear

Question 6

Signs of compassion fatigue, stress and burnout?

Answer 6

1. Anger, blaming, irritability (Ian Couper: lack of insight)
2. Depression, diminished sense of personal accomplishment (Couper: loss of meaning)
3. Exhaustion physical and emotional (Couper: lack of focus, mistakes)
4. Sleep disturbances
5. Social Isolation
6. Substance abuse

Question 7

System/process causes of adverse outcomes?

Answer 7

Lack of resources
Equipment failure
Nosocomial infections
Communication
- frequent in low income setting

Question 8

Doctor/student causes of adverse outcomes?

Answer 8

1. Clinical decision
2. Wrong medications
3. Wrong procedure
4. Carelessness

Question 9

Prevention of the system problem as the cause of adverse events?

Answer 9

1. Devise system change
2. Improve team communication
3. QI

Question 10

Prevention of cognitive error as the cause of adverse events?

Answer 10

1. Analyse the case, make DD, do further study
2. Analyse internal & external factors
3. Professional awareness

Question 11

How to keep the doctor fit to prevent adverse events?

Answer 11

Get into the habit of doing something every day that will replenish you:
1. Spend time with friends and family
2. Support groups
3. Exercising
4. Nutritious eating
5. Prayer or meditation / still the mind
6. Be present in the moment.