CT27A HISTORY OF ERRORS AND THE CHRISTCHURCH SOLUTION

• Published in: ANZ journal of surgery 2007-05, Vol.77 (s1), p.A13-A13
• Main Author: Shaw, D. P.
• Format: Article
• Language: English
• Subjects: Clinical outcomes; Health care delivery; Medical errors; Patient safety; Rules; Side effects
• ISSN: 1445-1433; 1445-2197
• DOI: 10.1111/j.1445-2197.2007.04115_25.x

An adverse outcome represents the sumation of many different errors. These errors may be equipment related, process related, personnel related etc. When the summation of these errors reaches a critical point an adverse outcome occurs. After a personal analysis of adverse outcomes the below 5 rules were instigated. The author believes that a large number of adverse medical outcomes could be avoided by the adherence of these rules. Such a system of rules removes the reluctance of many junior staff to contact their seniors, instead it acts as a compulsory communication protocol between the senior and junior staff. These rules form part of the resident staff orientation. They are displayed in the nurses office on the ward and each resident is given a laminated credit card size version to clip to their hospital ID. The rules are: 1. All referrals outside the service must be approved by a Registrar or Consultant 2. Ensure patients have a management plan 3. Ensure adequate patient records are maintained (objective, no personal conclusions, not inflamatory) 4. Instructions from those above in the chain of command cannot be countermanded by those below without discussion with those issuing the instructions 5. If you don't know - ask, you should never feel out of your depth [PUBLICATION ABSTRACT]