Reducing risk and improving client care
L. Forster, U. Bankowska
The Sandyford Initiative, Glasgow, UK
Objective: To establish a reporting framework for adverse events
within a community sexual and reproductive health clinic setting as part of the
risk management plan.
Method: The Sandyford Initiative adverse event framework was
redeveloped in 2002 to accommodate the requirements of an integrated
contraceptive, reproductive and sexual health service. This involved encouraging
the reporting of all events involving clients or staff, the data gathered being
used as a learning set to encourage root cause analysis and so minimise the risk
of incident recurrence. The structure and process to be followed was clearly
laid out in training and an algorithm developed to facilitate the integration of
the new framework.
Results: Individual events are evaluated and responded to by a senior
clinical team. Adverse events have been categorised into 15 significant event
types including clinical events, confidentiality breaches, difficulties in
access to appropriate services, treatment delays and health and safety issues.
An action grid for organisational changes is formulated and a designated
individual nominated to ensure that remedial action is completed. Interim
reports are available for all staff and published annually in the clinical
governance report. Regular teaching sessions are formulated around issues that
have compromised client care.
Conclusions: The process may seem complicated and time consuming, but
the experience of its use suggests that focusing on key issues and bringing out
the system factors behind an incident can save time. A formal systematic
approach can benefit staff by moving away from a culture of blame to one of