Adverse Incidents an IPL learning opportunity

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Adverse Incidents- an IPL learning opportunity?

• Dr Fiona McCullough
• Course manager for dietetic programme

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The examples keep hitting the headlines

• Adverse incidences highlight a number of
  causative factors in particular poor
  communications between professionals.
• Colwell Report (1974)
• Kennedy Report (Bristol Royal Infirmary)
• Laming Report (Victoria Climbié)

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Student Conference Learning Outcomes

• Identify individual profession roles and the
  factors that influence effective partnership
  working.
• Consider professional codes, legislation and
  social policy that influence the partnership and
  decision making process.
• Apply knowledge, experience and understanding of
  IPL to an adverse incident case-study.
• Reflect and conclude individual learning of IPL
  on care delivery, decision making and partnership
  working.

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Introductory activity addressing misinformation
and stereotypes

• Roles and responsibilities task involves the
  learners having their professional label on their
  back.
• Other learners then label each professional-
  regarding
• Role
• Responsibilities
• What one thinks they are like?
• Characteristics
• The task is followed by facilitated IP group
  feedback.

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Main focus

• 45 minute presentation about an adverse incident
  in health and social care conveying the facts of
  the incident
• Small group work (n10) discussion
• The process, communication and other factors
  contributing to the incident
• How can Adverse Healthcare Events like
  this be prevented?
• How may Inter-professional Learning enhance care?

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An isolated incident?

• SINCE 1985 13 CASES OF PEOPLE KILLED OR
  PARALYSED DUE TO THE MALADMINISTRATION OF DRUGS
  BY SPINAL INJECTION
• An organisation with a memory 2000

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Practical aspects increasing the risk of human
error
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Social aspects Barriers to effective
communication
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The consequences of inadequate communication
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Plenary session lessons learnt

• Communication Written, Verbal non-verbal with
  all parties
• Recognise own limitations need knowledge of
  others abilities and expertise
• Consent
• Respect for all members of the multidisciplinary
  team communication helps remove culture of fear
• Teaching two way process teach and question
  discussion is important
• More liaison Interdisciplinary patient and
  carer/family
• Work as a team multidisciplinary into
  interdisciplinary
• Understand roles of others
• Compliance v concordance patient involvement
• Patient centred care Teamwork recognise
  importance of all members of the
  multidisciplinary team
• Dont become complacent when treating patients
• Check everything before you proceed
• Break the borders of hierarchy

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Selection of student comments

• Physiotherapy
• Today has had a significant impact on my future
  practice - referring to adverse health care
  event
• Midwifery
• I have been encouraged to focus on my own
  practice and accountability
• Emphasised the importance of team work
• Nursing
• I was surprised by other disciplines perception
  of my role.
• Medicine
• Such days are required for everybody to hear
  the opinions of other health professions
• Useful to correct stereotypes these start in
  the first year and need corrected from the
  start.
• Dietetics
• IPE needs to start in the classroom
• Pharmacy
• Useful for reducing stereotyping.