Reducing risk and improving client care

Reducing risk and improving client care

L. Forster, U. Bankowska

The Sandyford Initiative, Glasgow, UK

Objective: To establish a reporting framework for adverse events

within a community sexual and reproductive health clinic setting as part of the

risk management plan.

Method: The Sandyford Initiative adverse event framework was

redeveloped in 2002 to accommodate the requirements of an integrated

contraceptive, reproductive and sexual health service. This involved encouraging

the reporting of all events involving clients or staff, the data gathered being

used as a learning set to encourage root cause analysis and so minimise the risk

of incident recurrence. The structure and process to be followed was clearly

laid out in training and an algorithm developed to facilitate the integration of

the new framework.

Results: Individual events are evaluated and responded to by a senior

clinical team. Adverse events have been categorised into 15 significant event

types including clinical events, confidentiality breaches, difficulties in

access to appropriate services, treatment delays and health and safety issues.

An action grid for organisational changes is formulated and a designated

individual nominated to ensure that remedial action is completed. Interim

reports are available for all staff and published annually in the clinical

governance report. Regular teaching sessions are formulated around issues that

have compromised client care.

Conclusions: The process may seem complicated and time consuming, but

the experience of its use suggests that focusing on key issues and bringing out

the system factors behind an incident can save time. A formal systematic

approach can benefit staff by moving away from a culture of blame to one of


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