Synopsis

We come to work each day to do the very best for our patients, however in some instances, patients are harmed by the care that was intended to help them.  Such clinical incidents affect not only the patients and families, but also the well-intentioned staff.  Problems are confounded if information is not provided and there are gaps in learning and improvement. In the busy clinical environment, incidents may be discussed but not thoroughly investigated to understand what happened and why. We need to know what systems issues and human factors lead to the clinical incident.  Incident investigations when done properly can provide a mechanism for something positive to come from very difficult situations.  This assists families and staff to understand what happened and what improvements could be made to prevent similar harm to other patients in the future. A most important part of a critical incident investigations is sharing the learnings from these reviews.

Speaker

DianneTucker is the Director of Quality and Improvements.  One of the teams she leads in the organisation is the Clinical Risk team, comprised of Clinical Lead (Nadine Stacey), Medical leads (Annie Moulden and Romi Rimer) and Clinical Risk-Improvement managers (Sharon Smith and Debra Newnham). Di’s background is as a Medical Scientist, and she has worked at the RCH for over 30 years.  The past 20 years have been in Quality Management. In 2013, Di joined the (what was then) Strategy and Improvement department and has been Director of (what is now) Quality and Improvement since 2014. Di is passionate about ‘system and process’ and with the team have introduced a new Clinical Incident Analysis Framework to ensure that the RCH undertakes robust and meaningful incident investigations with a focus on systems thinking and human factors. With the introduction of VHIMS2 and the incident analysis framework, we are confident that by providing capability to all our clinical teams, we can ensure that incidents are reviewed with the purpose to learn and improve.