Risk Management and Safety Communication Strategies
|Type||Public / Private|
An adverse event is any untoward medical occurrence in a patient or clinical-trial participant administered a medicinal product and which does not necessarily have to have a causal relationship with this treatment and can lead to any unfavorable and unintended sign (including an abnormal laboratory finding), symptom, or disease temporally associated with the use of a medicinal (investigational) product. Awareness while under anaesthetic, deaths during surgery, and missed cases of meningitis are tragic for both patients and staff, and may lead to complaints or litigation. Investigations usually focus on the actions of individual doctors and seldom examine the background to these events.
In a recent case of a patient whose bowel was perforated during surgery, examination of the medical records led to criticism of the surgeon. Only later did it emerge that the operation had been carried out in near darkness because of several equipment and power problems. Adverse events usually originate in a variety of systemic features operating at different levels—the task, the team, the work environment, and the organisation. We present a framework that aims to encompass the many factors influencing clinical practice. It can be used to guide the investigation of incidents, to generate ways of assessing risk, and to focus research on the causes and prevention of adverse outcomes.
Most recent case of a patient who had undergone craniotomy procedure had IV infiltration in the left arm which was unintentionally performed by a nurse while the patient was in the ICU for 18 days. The nurse had inadvertently inserted the IV canulation into the layers of the skin rather than the vein. This in turn had accumulated all the fluids administered by the IV route into the subcutaneous layers of the skin. All the layers of the skin get removed and it had let the worst wound on the skin. This leads to the evolution for the need of risk management and safety communication strategies. So, in clinical practice safety measurements are the most important part for the involvement of the good care for the patient.
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Nigerian surgeon in UK removes woman’s ovary instead of appendix
A senior Nigerian surgeon, Dr Lawal Haruna, has been struck off in the UK after accidentally removing a woman’s ovary instead of her appendix.
The 59-year-old mistook the patient’s reproductive organs for her appendix when she was admitted to hospital with abdominal pain.
The unnamed “Patient B”, who was not of child-bearing age, also had her fallopian tube removed during the bungled procedure.