kithumbus - PATIENT SAFETY INCIDENT MANAGEMENT In a culture...

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PATIENT SAFETY INCIDENT MANAGEMENT In a culture of patient safety, everyone is encouraged to report and learn from patient safety incidents, including harmful, no-harm, and near miss. A reporting system that is simple (few steps), clear (what needs to be reported, how to report, and to whom), confidential, and focused on system improvement is essential. Clients and families may report patient safety incidents differently than team members, but everyone needs to know how to report. Information about how to report can be tailored to the needs of team members or clients, and can be part of team member training and included in written and verbal communication to clients and families about their role in safety The immediate response to a patient safety incident is to address the urgent care and support needs of those involved. It is also important to secure any items related to the incident (for testing and review by the analysis team), report the incident using the approved process, begin the disclosure process (if required), and take action to reduce any risk of imminent recurrence. Through incident analysis (also known as root cause analyses), contributing factors and recommended actions can be identified in order to make improvements. Analyzing similar patient safety incidents (such as near misses) together, to look for patterns or trends, can yield helpful information, as can analyzing incidents in isolation. Communicating incident analysis findings broadly (e.g., with clients and families, governance, leadership, clinical teams, and external partners) builds confidence in the incident management system and promotes learning from patient safety incidents. INFORMATION TRANSFER AT CARE TRANSITIONS Effective communication is the accurate and timely exchange of information that minimizes misunderstanding. Information relevant to the care of the client will depend on the nature of the care transition. It usually

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