Ealth Management Managing the aftermath of an adverse safety incident


Managing the aftermath of an adverse safety incident


***A written report, exploring aspects of managing the aftermath of a patient safety incident, with a rationale for action supported by evidence.

How can a manager effectively manage the aftermath of a patient safety incident?

Explore the options available and support them based on current best evidence. You may explore the general topic as a whole a supported by evidence or examples, or focus on one incident in particular. You might suggest what was done, how effective it was and what could be done to improve the management in the future. You should focus on:
- Help for the first victim
- Help for the second victim
- System improvement for the future

Give a short conclusion and make recommendations for the future.

a? Please could you write something about the ishikawa diagram and root cause analysis also.


1. Critically analyse the role and impact of clinical governance in safe healthcare
2. Analyse the role of human factors in the design of safe health care processes and equipment.
3. Evaluate the role of safety culture and safety climate in the prevention and mitigation of harm.
4. Apply methods and systems to manage the aftermath of a patient safety incident.





Reading and resources for the module:
Dekker S (2007) Just Culture. Balancing Safety and
Accountability. Surrey UK, Ashgate.
St Pierre M, Hofinger G, Buerschaper C (2008) Crisis
Management in Acute Care Settings. Berlin, Springer.
Vincent C (2006) Patient Safety. London, Elsevier.
Wachter RM (2007) Understanding Patient Safety. McGraw Hill
Amalberti R, Auroy Y, Berwick D, Barach P (2005) Five system
barriers to achieving ultrasafe healthcare. Annals of Internal
Medicine v 142 (9) pp765-764.
Department of Health (2000) An organisation with a memory:
learning from adverse incidents in the NHS. The Stationery
Office, London.
Helmreich RL (2000) On error management: lessons from
aviation. British Medical Journal v 320 pp781-785.
Khatri Hughes LC, Chan Y, & Mark B (2009) Quality and
Strength of patient safety climate on medical-surgical units.
Health Care Management Review v34(1) pp19-28.
N, Brown GD, Hicks LL (2009) From a blame culture to a just
culture in health care Health Care Management Review v34(4)
Kramen SS, Hamm G (2002) Risk management: extreme
honesty may be the best policy. Annals of Internal Medicine
v131 pp963-967.