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By Root 1920 0

extremely stressful and at times upsetting. It is important that if a nurse is involved in an adverse event, they seek and are given appropriate support and guidance in order to learn from the event and prevent its reoccurrence in the future. The nurse has an obligation to report any incidents which occur, and to act in a transparent and open manner. Box 4.1 highlights the action which should be taken if a nurse believes an incident has occurred. Nurses can test their knowledge of risk management by working through a checklist (Box 4.2).

Box 4.1 Priorities in the event of a patient safety incident

Immediate

Mitigate harm by taking immediate action within the scope of professional practice and call for help if the patient is at risk of further injury or harm.

Remain calm and offer an initial explanation to the person or people involved.

Take action to prevent immediate reoccurrence of the incident.

Report the incident to a senior member of staff.

Short term

Complete an incident form (depending on the organization, this may be in electronic format), assessing the likelihood and consequence of the risk reoccurring.

You may be asked to be involved in a root cause analysis (RCA) event. This is a structured process for analysing how the incident occurred, what the main causes of the incident were and how it can be prevented in the future.

Discuss the incident one to one with your manager, identifying any areas of specific training or support you may require to prevent reoccurrence of the incident.

Long term

Ensure that actions resulting from the RCA or incident investigation are followed up and completed.

Work with the ward/departmental team to audit the lessons learned and actions taken.

Box 4.2 Risk management – how do you do?

Yes No

1 Have you undergone risk management training within your organization?

2 Do you understand the organization’s risk management and incident reporting policies?

3 Do you comply at all times with the relevant risk management strategies and policies?

4 Do you know what the three top risks are in your clinical area and what action has been put in place to mitigate those risks?

5 Do you report to your line manager if you have any concerns regarding risks or patient safety?

6 Do you follow up to see if any action has been taken?

7 Are you familiar with/ have you had training on the specific patient risk assessments in your organization?

Manual handling?

Pressure area assessments?

Nutritional assessments?

Infection control assessments?

Falls assessments?

8 Are you competent to use all the equipment you are currently using?

9 Do you identify with your line manager any areas of your practice in which you require further training?

10 Do you discuss risk management with your patients and their families where appropriate?

11 Do you know how to complete an incident form?

12 Have you had training on how to undertake root cause analysis?

13 Do you regularly access the National Patient Safety Agency website to keep updated?

The assessment and mitigation of important clinical risks

In clinical practice there are some risks that have been highlighted nationally and internationally as both largely preventable and, if they occur, causing major morbidity, suffering and high financial costs. Three key examples of these are the prevention of:

venous thromboembolism (VTE)

pressure ulcers

falls.

Venous thromboembolism

Related theory

The prevention of venous thromboembolism

Each year over 25,000 people in England die from VTE contracted in hospital (House of Commons Health Select Committee 2005).

The main danger is from pulmonary embolism (PE). A thrombus forms in the lower limb or pelvic veins and then travels in the blood and lodges in the lungs, leading to acute massive PE, which has a high mortality rate. The initial thrombus is called a deep vein thrombosis (DVT). A DVT is itself a cause of substantial morbidity and may lead to the development of post-thrombotic syndrome (in around 30% of people with DVT), which is associated with chronic swelling and ulceration