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Patient Safety Consultancy Services

Clinical audits related to patient safety

We design clinical audits related to patient safety issues for organizations or clinical services. We work with the clinical and/or management team members to:

  • reach consensus on the purpose and specific objectives of the audit
  • identify the people who are going to be involved and how they will be involved
  • agree on the population or sample of cases to be included in the audit and how cases will be identified
  • select the best strategy for data collection given the objectives of the audit
  • develop valid and workable measures of quality and/or safety of patient care
  • devise a data collection protocol and data collection tool
  • impose data protection provisions in the collection, collation and analysis of data
  • flag any ethics issues that might arise in the clinical audit for local resolution
  • recommend approaches for analysis of the findings of the clinical audit, including how to analyse problems revealed by the audit and plan and implement action needed.
Evidence-based patient safety policies and procedures

We work with clinical teams and patient safety-related managers and committees to develop specific patient safety-related policies and procedures based on analysis of related evidence.

Reportable clinical incidents

We have searched clinical literature and identified reportable clinical incidents reported in the literature. In order to promote better reporting of incidents and adverse events, we work with risk managers and risk management committees to inform clinical staff about the types of clinical events that should be reported and that have been reported and described in the clinical literature.

Root cause analysis of a serious adverse event or complaint

On request, usually for sensitive or extremely serious circumstances or events, we lead or facilitate root cause analysis of a serious adverse event or complaint. We:

  • gather or direct the gathering of detailed information about the event, including identifying whether or not there is a cascade of previously unrecognized or unaddressed incidents or events
  • obtain or direct the obtaining of any materials, equipment, devices, supplies and detailed information about the location(s) involved of the event, staffing levels at the time(s) involved, documentation in relevant patient records, and the recollection of the people involved in the event
  • describe in detail the key processes or systems related to the event, specifically the intended process, the process staff usually follow and the process followed in the actual event
  • analyse the information gathered to identify the causes of the breakdown in work processes or systems that enabled the event to occur, or that didn’t act to prevent the event from occurrence
  • devise the actions needed to prevent the same type of event from occurring again and an action implementation plan
  • measure the effectiveness of implementation of the actions to minimize the recurrence of the same or similar event.

We document the entire analysis and provide a report to those responsible.

Failure mode and effects analysis for a clinical service

We lead or facilitate failure mode and effects analysis (FMEA) of high-risk clinical processes. We:

  • help organizations and clinical services identify high-risk clinical processes in which risk could be reduced or minimized through the FMEA process
  • work with clinical teams to describe in detail exactly how a high-risk process is carried out now
  • identify with clinical teams where and how the current process could fail
  • work with clinical teams to make judgements about the potential impact of each potential failure and identify the most serious failures that need to be prevented or minimized
  • develop the actions needed to prevent any failure that would have a serious impact on patients and support teams in implementation of the actions
  • measure the effectiveness of implementation of the actions to minimize the impact of potential failures in the process.

We document the entire analysis and provide a report to those responsible.

 

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