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Medical Error NPSA

Medical Error NPSA

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Published by: luifel2780 on Nov 11, 2010
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06/06/2014

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MEDICALERROR
What to do if things go wrong:a guide for junior doctors
issue 02
JUNE 2010
A year into my frst post as a general consultant  physician I made a mistake that will always live with me” 
Junior doctors are oten at the rontline and must takeresponsibility or ensuring that details o the incident areincluded in the patient’s medical records
Patients have the right to expect openness intheir healthcare
Fear or concerns over blame should not prevent yourom being open and honest about what happened
Your position as a junior doctor, on the rontline o care,is vital in the identication o learning rom reporting
“Within two weeks o my frst registrar post,I’d made an error that nearly cost my patient her lie…The patient complained. I was devastated” 
I LEARNED thE IMpORtANCEO kNOwINg yOUR pAtIENtAND thE NEED tO pAy ENDLEssAttENtION tO DEtAIL.”
Pess S Gee Ctt
I CARED pAssIONAtELy AbOUtthIs pAtIENt, bUt OUND thAtI AM pERECtLy CApAbLE OORgEttINg thINgs.”
Pess Esbeth Pce
 
The National Patient Saety Agency (NPSA)would like to thank the Medical Deence Union(MDU) and the Medical Protection Society(MPS) or contributing to and supporting thispublication. We would also like to thank allthe individuals who are eatured or reelyproviding personal stories or comments on thesubject o medical error and patient saety.The personal stories and comments are truebut identiying details have been changed toprotect people’s condentiality. Cases rom theMDU and the MPS are ctitious, but based oncases rom les.
Ediorial Commiee
 
kevin Clear
 Medical Director, NPSA
sumee panear
 Clinical Advisor to the Medical Director, NPSA
Vivian tan
 Clinical Advisor to the Medical Director, NPSA
Andre Caron-seven
 Final year medical student, Cardi Universityand Wales Chapter Leader, Institute orHealthcare Improvement Open School orHealth Proessions
Darren oler
 Specialist Registrar in Paediatric and PerinatalPathology at Great Ormond Street Hospital/ University College Hospital London
paul gran
 Clinical Leadership Fellow, Royal Sussex CountyHospital, Brighton
Andre heale
 Specialist Registrar in General Surgery,Chelsea and Westminster Hospital NHSFoundation Trust, London
Aleia hun
 CT1 Core Medical Training, University HospitalLewisham NHS Trust
Roi Juneja
 Specialist Registrar in Anaesthetics and ClinicalFellow in Patient Saety and Simulation, TheRoyal Marsden NHS Foundation Trust/Chelseaand Westminster Hospital NHS FoundationTrust, London
kae Mandeville
 National Institute or Health Research AcademicClinical Fellow in Public Health (UniversityCollege London Inection and PopulationHealth)
Colm McCae
 Specialist Registrar in Respiratory Medicinebased at Wexham Park Hospital, Slough
tom Nolan
 GP ST1, King’s College Hospital, London
Damian Roland
 Chair o the Royal College o Paediatrics andChild Health Trainees’ Committee, AcademicClinical Fellow in Paediatric EmergencyMedicine, Leicester Royal Inrmary
Oer conriuor:seanie bon
 Director o Policy and Communications, MPS
gare gilleie
 Senior Editor, MPS
Emma Cuzner
 Medico-legal adviser, MDU
Emma ore
 European Patient Saety Network and PatientEngagement Lead, NPSA
tara Lamon
 Head o Response, NPSA
peer hauon
 Senior Adviser in Medical Ethics and Law,Division o Medical Education, School oMedicine, King’s College London
ACkNOwLEDgEMENts
2—mEdiCal ErrorJUNE 2010
 
CONtENts
A patient safety incident occursDocument the incident in the patient’s recordsInform the patient and their family/carersand apologiseReport the incident via your localreporting systemHow will my report inform localand national learning?What happens if the patient makes a complaint?
whAt shOULD I DOI I AM INVOLVEDIN A pAtIENtsAEty INCIDENt?
mEdiCal Error —3

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