Learning from error
1: Identify the barriers to reporting error.
-Use an example from your practice to describe the process used
-Look at the research/literature – robust and reliable evidence? Reflect on it in your own practice.
-Use tables and different media etc.
-What about near misses? Does the literature reflect on the barriers of reporting these?
-Is there a culture of transparency?
-How do you close the loop – what happens when an error is reported?
-How can no reporting influence practice? How do you know? What do you do and how do you share experiences? Does it facilitate change?
-Does anything change?
2: Using an example from your practice describe the reporting process when an error has occurred.
-Chose one you feel is common – you can use previously identified error from Human factors section or a different one.
-Mainly descriptive but can refer to the literature to discuss similarities and differences etc.
-Legal requirements – Duty of Candour – The introduction of a statutory duty of candour is an important step towards ensuring the open, honest and transparent culture – discuss and apply to your example
3: Think about a recurring error in your practice,
a. discuss which of the tools could be used to understand the causes. Reflection of literature to practice; demonstrate that you understand what they are and how applied in different circumstances. What is the most appropriate tool for your problem?
b. why have you chosen that tool? Add a diagram demonstrating its use (applied to the problem).