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Healthcare Waste Management Conference in Africa Today

Healthcare Waste Management Conference in Africa Today. Incident Reporting A Proactive Approach. Janet Magner Healthcare Consultant Magallan Risk Services. Accidents re-occur because we do not use the knowledge we already have. Learning from Losses.

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Healthcare Waste Management Conference in Africa Today

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  1. Healthcare Waste Management Conference in Africa Today Incident Reporting A Proactive Approach Janet Magner Healthcare Consultant Magallan Risk Services

  2. Accidents re-occur because we do not use the knowledge we already have Learning from Losses “We are slow to learn from Experiences of Others” Trevor A. KetzChemical Engineer

  3. “Modern man peers eagerly back into the twilight out of which he has come, in the hope that its faint beams will illuminate the obscurity into which he is going” E.H. CarrHistorian

  4. “ It is searchlights, not faint beams that shine out of the past and show us the pits into which we will fall if we do not look where we are going” Trevor A. KletzChemical Engineer

  5. “Normalisation of Deviance” • Risk is relative • We increase our ability to accept risk • Complacency develops Corrie J. Pitzer - MD SAFEmap Australia

  6. Eeufees Disasters – 19 in 5 yrs

  7. The healthcare environment • HC workers suffer 600,000 – 1 million injuries from needles and sharps annually • At least 1000 HC workers estimated to contract serious infections annually from needlestick and sharps injuries • Approximately 3% of needlestick injuries result in HIV exposure • Approximately 30 needlestick injuries / 100 beds / year Nursing Facts -American Nursing Association / EPINet 1999

  8. “Moving towards depravity” Pascal

  9. What is an Incident? An unplanned sequence of events which has caused (or could have caused) loss. (death, injury, illness, environmental or property damage, or business interuption, legal liability) Or could have caused = potential for loss =Near Miss

  10. The accident / near miss relationship

  11. What conclusions can be drawn? There are more opportunities for learning from our own and other’s experiences than we can realistically process! The Near Miss is a free object lesson !

  12. Why do we not know about them? • Organization Culture • Fault finding rather than Fact finding • Not wanting to be found “Incompetent” • Time wasting - extra work • Lack of trust • Fear of reprisals

  13. Near miss reporting in healthcare • Formulation of a healthcare industry wide CEO level task force • Blue Cross Blue shield or Michigan Foundation • American Safety Health - System Pharmacists (ASHP)

  14. Key areas and position • Uniform Nation-wide system of mandatory reporting • Voluntary reporting of medical errors • Protection granted • Implementation of process channel • Research analysis and communication

  15. ASHP News – 18/07/2003 • “There is no reluctance to talk about it any more…….” • “5 to 8 years ago errors were something to sweep under the carpet and you don’t know you have a problem unless you look under the carpet” • “Anonymous-reporting policy led to the volunteer non-punitive-reporting policy now in place” • ….brainstorm how we can improve” • “the drop boxes have increased the number of near miss reporting by 5 times”

  16. Criminal implications of reporting • Incriminating - legal liability • Loss of confidentiality • Punitive, Threatening • Demotivating

  17. Process to Follow – R E P O R T

  18. React positively • Attitude of Line Manager • Team Approach • Well Trained • Objective

  19. Evaluate Cause • Systematic Approach – Causal / Fault Tree analysis • Analyze through to basic (underlying cause) • Good questioning techniques - 5 Why’s

  20. Prevent a recurrence • Comply with Policy • Effectively applied • Risk not shifted • Short and Long term solutions

  21. Opportunity to Share • Demonstrate Concern • Cost Implications • Develop a culture of learning (Also stands for Organized Approach)

  22. Report Form “The job is not complete until the paper work is done” Easy to use Readily available Distinctive colour All the necessary legal requirements

  23. Trend Analysis Trevor A. KetzChemical Engineer

  24. Summary • Learn from Experiences of Others • Learn from our Own Experiences • Develop a culture of Non Blame / Fact Finding / Trust • Set up a reporting system that will identify and analyze critical behaviors REMEMBER - R E P O R T

  25. 3% of needlestick injuries result in HIV exposure!

  26. Healthcare Waste Management Conference in Africa Today Incident Reporting A Proactive Approach Janet Magner Healthcare Consultant Magallan Risk Services

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