M2 Systems analysis of clinical incidents

M2 Systems analysis of clinical incidents

Format: Interactive teaching, group work, Q&A, and discussion

This course will discuss the realities of undertaking investigations and what aids the process. Issues such as investigation commissioning, developing appropriate terms of reference, proportionality, why obtaining consent is important, and what obstacles can affect this process and how they can be overcome will be covered, together with developing failsafe cost-effective recommendations and ensuring evaluation. The course will include the use of the London Protocol (translated in 16 languages and used internationally), practical examples from past incident investigations, the need to include the patient and their relatives, and the role of causal analysis.

After this course you will be able to:

• Understand the theoretical and practical framework for systematic incident analysis using the London Protocol
• Develop practical expertise in undertaking causal analysis work
• Understand the organisational realities of undertaking systematic investigations and analyses
• Realise the advantages of engaging all stakeholders in systematic investigation processes and the importance of disclosure

Charles Vincent, Professor; Sally Adams, Research Fellow, Clinical Safety Research Unit, Imperial College London UK; Christine Jorm, Senior Medical Advisor, Australian Commission on Safety and Quality in Health Care, Australia