An Incident of Poor Practice: Focusing on Identifying and Responding to an Error
This is a report (1500 words) on an incident of poor practice, focusing on identifying and
responding to an error or to poor practice.
This report could be structured like this:
1. Introduction. Students should outline what this report will cover (150 words)
2. Students should analyse the role of individuals, teams, employers and professional,
statutory and regulatory bodies in the delivery of safe and effective health and social
care (400 words)
3. Students should link and reference a statement of event (attached as an appendix)
on an incident of poor practice in simulation. The focus is on identifying, reporting
and responding to an error or poor practice. Links should be made to service
improvement, clinical governance and to your specific professional standards (500
words)
4. Students should reflect on their contribution to safe and effective person centred
care - this section can be written in the first person (300 words)
5. Conclusion - do not introduce new ideas in this section (150 words)
You are able to choose what situation/scenario you write your report on - this is to keep the
assessment real to practice, as health professionals often have to respond to an
investigation and write a report days/weeks or months after an event from the notes that
they had written when delivering the care.
As part of this assignment you are required to complete a ‘Statement of Events’. A template
for this has been created and will be uploaded to the Moodle site. This replicates an in
hospital incident report and can be used to create your own statement of events. The aim of
this is to support your 1500-word report and includes relevant information on how to
complete it correctly. The ‘Description’ section should be an objective and factual account of
what happened during the episode of poor practice.
This report must be supported by relevant references. Your references could include the
professional Codes, NHS Constitution and any other key information relating to the
domains.
Reporting an incident
Who does the incident affect?
• Patient (In-patient, Out-patient, Day Case Patient)
• Staff (Trust Employee, Volunteers, Students, Agency/Locum)
• Visitor/Contractor/Member of the Public
• The Organisation (e.g. IT, Information Governance, Services, Premises)
Person(s) Affected:
• Type (choose from list above e.g. In-Patient):
• Title:
• Patient/staff number:
• Gender:
• Ethnicity:
• Was the person injured in the incident? Yes/No
NB: In clinical practice, the reporter would be expected to provide the full name of the person(s) affected. However, you are not expected to for the purposes of this assignment.
Details of the incident
• Site (This is where the incident occurred – e.g. PHT, Out Patient Centre):
• Division (This is the division in which the incident occurred e.g. Medical Division):
• Type of location (This is the generic type of location where the incident occurred, e.g. ward, corridor, car park):
• Exact location (This is the specific location where the incident occurred, e.g. A&E, Maternity Ward, Pharmacy, etc.):
NB: In clinical practice, the reporter would need to enter in the Incident date (dd/MM/yyyy) and Incident time (hh:mm), however for the purposes of this assignment you will not be expected to do this.
Description:
• Category of incident (e.g. Blood and Blood products incidents / Direct Care (Patient Safety Incident) / Fall – Patient Slip, Trip or Fall)
• Only enter facts, not opinions, and avoid abbreviations.
• DO NOT ENTER THE nameS OF PEOPLE (Use job titles and roles instead – e.g. Patient, Nurse, etc.).
• Relate the facts from the beginning and keep them in chronological order, giving precise dates and times.
• Don’t speculate, elaborate or exaggerate, or use emotional language.
• Action taken (Enter action taken at the time of the incident):
NB: In clinical practice, the reporter of an incident usually has to risk grade which refers to the likelihood of recurrence. You will not be required to complete this for this assignment.
Mandatory Information:
• Was anyone else involved in the incident? Yes/No (e.g. witness, member of staff, etc.)
NB: In clinical practice, if the answer to this was ‘yes’, the reporter would need to add type of person affected, their title, forename(s), surname, patient/staff number, gender and ethnicity. You are not expected to do this for the purpose of this assignment.
• Was the person injured in the incident? Yes/No
NB: In clinical practice, the reporter usually has the opportunity to attach any relevant documentation to the incident form, such as a witness statement or photographic evidence, etc. You will not be required to complete this for this assignment.
This is the questionnaire that needs to be filled too
Thanks
An Incident of Poor Practice: Focusing on Identifying and Responding to an Error
Your Name
Subject and Section
Professor’s Name
Date of Submission
Introduction
There has been an increasing incidence of clinical error claims in the medical field secondary to the rising figures of disabling diseases and injuries due to medical negligence and other interventions applied during hospitalization. This results in an upsurge in the days of hospitalization and finances to the patient’s part and an escalation of the records of lawsuits (Oyebode, 2013).
The National Health Service (NHS) is the regulatory body in the United Kingdom which is responsible for managing the claims of legitimate patients against clinical negligence. The NHS reported paying approximately 12, 000 claims in 2013-2014 secondary to clinical errors (Medical Malpractice Center, n.d.)
The objectives of this paper are to discuss the particular roles of nurses, doctors, operating department practitioners, hospital administration, and the regulatory bodies in preventing medical errors through the use of medical guidelines. Furthermore, this paper discusses the significance of student contribution in the promotion of a safe and effective patient-centered care.
Specific Roles in Proper Healthcare Delivery
Researchers have described models of causation of human error which include the person-centered and the systems approach. The person-centered emphasizes the individual faults attributed to forgetfulness, negligence, or moral failure. By contrast, the systems approach focuses on the settings where the healthcare workers operate as the primary foundation of the origin of errors in the clinical setting. Nevertheless, human errors contribute to the majority of clinical errors rather than technical difficulties and malfunctions and these errors pose occupational and patient-related hazards (Oyebode, 2013).
Due to these factors, the members of the healthcare team and the administration are designated specific roles to combat the aftermaths of these events. Moreover, each person has specific responsibilities in preventing such situations.
Roles of Individuals
Clinical governance for each specific medical profession. CPGs are designed to mend the quality of care provided to the patients by attempting to connect the variations of methods and techniques in clinical practice, harmonizing the overuse and underuse of medical facilities, and offering a platform of communication for outcomes-based and cost-effective clinical practices (Mackey & Liang, 2011).
The primary role of individual healthcare professionals is to follow the CPGs stated by their principal organizations. Each individual is required to adhere to the standards of practice and hospital protocols. Additionally, having good communication skills, proper endorsement of activities, and excellent patient rapport and understanding may also aid individual practitioners to lessen medical malpractices (Mackey & Liang, 2011).
Roles of the Healthcare Team
A healthcare team is composed of diverse types of medical professionals. Due to this, there may be disagreements in making the proper decisions related to the patient’s well-being The primary role of a healthcare team is to promote excellent communication and harmony among team members, to create a proper process of disseminating information, and to properly execute the treatments (Ballard & Grant, 2017).
Each member of the healthcare team shall adhere to the Health & Care Professionals Council (HCPC) professional standards to improve the quality of care provided for the patients. Moreover, the HCPC provides guidelines on the expectations of a medical practitioner’s knowledge and abilities, indorses programs to prepare fresh graduates to meet the set standards, and summarizes the public expectations from the licensed professionals (Health & Care Professionals Council, n.d.).
Roles of Employers
Respondeat superior exemplifies the universal rule that the proprietor is also accountable for the negligent acts or lapses of its employees acting within the course and extent of his service. This is based on the fact that the employer has the obligation to properly execute protocols and to designate the specific actions of its employees (Thornton, 2010).
Roles of Regulatory Bodies
In the United Kingdom, the primary regulatory body is the NHS which is responsible for compensating claimants for clinical negligence. These payouts are made to compensate for the public scandals secondary to poor quality care and substandard methods of practice. The claims for these damages can also be attributed to the increased health risks, mistakes, and failure of diagnosis, surgical malpractices, and prescription drug errors (Medical Malpractice Center, n.d.).
Clinical Errors and Incident Report
The case presented in Appendix A is an example of a hospital incident concerning the student ODP. This is a case of racism and harassment against the student ODP done by the patient, named Mr. BC for confidentiality.
Mr. BC approached the student to book for a clinical check-up. However, several patients need to be examined first before him. He insisted that he needs to be examined as soon as possible and threatened the student by telling him that he has brought dangerous objects such as knives. Mr. BC also seemed to be determined to hurt the student ODP when he deems that it is necessary. Moreover, he has inflicted negative words about the student’s immigration status.
In this case, the student ODP adhered to the standards of proficiency of HCPC, particularly with the following: 1) Understanding the demand for the respect of patient rights, dignity, and values.; 2) Assessing the professional situation and establishing the seriousness of the patient’s situation.; 3) Valuing cultural diversities and equality on practice.; and 4) Effective communication (Health & Care Professionals Council, n.d.).
However, the student ODP failed to fulfill the following standards of proficiency: 1) Sensitivity and mindfulness of the consequences of verbal and non-verbal communication based on the patient’s age, culture, ethnicity, gender, spiritual or religious beliefs, and socioeconomic status (Health & Care Professionals Council, n.d.).; 2) Understanding of the possible consequences of the clarity of communication with the patient to the assessment and engagement with the service users (Health & Care Professionals Council, n.d.).;. It has been noted in the case (see Appendix A) that the student ODP continued to smile despite the patient’s expression of distress. This made the patient more anxious and furious, thereby provoking him to threaten the student if his demands cannot be met in the shortest time possible.; 2) Assessing the professional situation and calling for help from people with better experiences concerning the case (Health & Care Professionals Council, n.d.). Upon realizing that the client needs special attention, the student ODP persisted to resolve the situation with her sole abilities despite being inexperienced. This is an oversight on the student’s part for the student must have asked for professional help from her superior staff.
The stated case calls for an improvement of the serv...
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