| Popis: |
Adverse events are clinical incidents that result in harm to patients or staff. The purpose of a clinical incident investigation is to learn from the incident and implement changes that make a difference. Clinical incidents reflect on how a system is working and identifies failures in the processes of care. The way in which incidents are managed is indicative of the culture of the team or organization. A just culture holds people accountable in a fair way and without blame. Transparency is essential and patients and families should be involved in the investigative process. Candour, too, is essential; and patients, families, and clinical teams should receive constant feedback on the investigation. This will enable learning and improvement in the processes of the system. |
