https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596 en-us 2021-03-29 01:28:34 UTC 2021-06-14 12:21:23 UTC hello@padlet.com https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1519774953 I was involved in a situation where a patient went into cardiac arrest and ended up dying. I was required to complete the paperwork and incident report after the situation. I was very nervous about the situation as I felt like I might be held accountable for what happened. However, my manager was very supportive and talked me through what would happen, they provided me with encouragement and reassurance. ]]> 2021-05-13 01:40:18 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1519774953 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1519780002 I was involved in a situation where a patient with dementia became aggressive and used a table to break a glass window. The patient then tried to use the massive shards of glass as a weapon. I remember when doing the incident report the manager was advising us not to put the situation as a SAC 1 as this would be escalated too high and not to make a scene. I felt this was wrong as it was a situation where it could have led to serious injury or death. All that was done as a result of the incident report was that the window was replaced (with glass) and the table was moved to another area. ]]> 2021-05-13 01:42:14 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1519780002 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1550464359 I have a real life experience when I repeatedly  completed Physically aggressive behaviour of the Client with Dementia; My supervisor discouraged me not to repeatedly write the incident for the same behaviour  frequently as it is a known behaviour and that strategies were in place.
Obviously we were not equipped to deal with such adverse Physical aggression and strategies were not effective. I was worried about other vulnerable Residents and the staffs.
I ended up quiting the job as I was a very fresh graduate; not feeling safe and very less experience to further raise the issues.]]> 2021-05-22 20:06:50 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1550464359 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1550901752 2021-05-23 05:37:25 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1550901752 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1551377158 2021-05-23 14:06:42 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1551377158 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1552823032 We had one manger who was very responsive and appreciative towards staff for taking the time to report incidents – this response defiantly encouraged a positive culture of reporting within our unit. ]]> 2021-05-24 06:15:06 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1552823032 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1552834810 A hospital I worked in rolled out a brand new hospital wide electronic system(we had previously been completely electronic so this process was not new just the program) and there were numerous program issues for potential adverse medication and documentation errors reported by nurses it was first all filtered through the IT department till they quickly became overwhelmed and we were told to report via riskman, weeks of reporting issues went by with minimal changes until a severe adverse event did occur resulting into a coroners enquiry before the organisation took swift measures and implemented the resources required to get the system working safely and efficiently. I really felt for the staff involved as they were truly let down by the organisation ]]> 2021-05-24 06:20:17 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1552834810 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1553173747 We had a manager who reviewed and responded to the IIMS reports that worked on the floor. She would follow up on incidents and ask for 'your side of the story'. She then went on to close any gaps in the incident before closing it down. It was this I think that made it worthwhile to report. However, we also had a period where we would fill out an IIMS, spending valuable time doing it, only to have it not submit. It was to do with how the majority of the computers were set up and most definitely deterred myself and others from reporting because it really was a waste of time. ]]> 2021-05-24 09:43:27 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1553173747 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1555822607 I believe my workplace holds negative conotabl]]> 2021-05-25 01:14:22 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1555822607 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1556692526 On one hand, the electronic reporting system is user friendly and I can generally find time throughout the shift to make a report. On the other hand, there is so little feedback and no witnessed change that I have experienced from any report I have made in my department that I do often question why I am making the time to make a report. ]]> 2021-05-25 07:16:56 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1556692526 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1557100339 in my LHD we use IMS+ reporting system.
My NUM always reviews the IMS reports and has open conversations with all involved to ensure everyone had a say and there were no gaps. The NUM has always made people feel comfortable to report no matter what the incident was. This has created a culture of safety and encouragement when using open disclosure while reporting ]]> 2021-05-25 10:42:49 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1557100339 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1559743961 2021-05-26 00:56:40 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1559743961 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1559903680 I reported an infection control issue where a patient was bought to theatre from the wards where it was only noticed in PACU that the patient was MRSA C.  This resulted in a shut down of the theatre the patient had been in for a terminal clean and the wastage of $$$ of items that were exposed.  PACU also had to be closed for a terminal clean, and patients moved, with all other patients having to be recovered in theatres causing a huge time delay.  The ward was aware of the MRSA C status but had not had the patient under precautions and failed to communicate this to theatre.  No feedback was received on this or any discussion with any staff members involved.  Simply that it had been closed.  ]]> 2021-05-26 01:59:10 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1559903680 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1559917854 Following a medication error in PACU, a policy was developed and education was given to staff hospital wide.  The event itself was a near miss with no adverse outcome, however it did show a lack of knowledge and training on this particular mode of delivery

]]> 2021-05-26 02:05:44 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1559917854 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1560082396 My workplace has been instrumental in redeveloping the online Incident Reporting System into a user friendly version which has yellow segments highlighted as compulsory fields, omitting all unnecessary fields. Its time saving and only takes a few minutes to fill. A great Q&I initiative to encourage higher reporting.]]> 2021-05-26 03:19:04 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1560082396 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1560089444 I regularly receive patients transferred to my department for step-down care from tertiary hospitals. We are required to report existing pressure areas on admission. It's surprising how many patients have them. The biggest issue is that we never receive any feedback on it. It feels like the mandatory reporting is only to absolve my workplace from blame regarding pressure areas, and is not used to feedback to other hospitals of the existing pressure area problem repeatedly coming from their health care.]]> 2021-05-26 03:22:37 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1560089444 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1560506926 when I was a new grad, I had a manager who discouraged me from reporting an incident with an aggressive patient. I didn't really understand why but being so junior I just went along with what she told me to do. ]]> 2021-05-26 06:58:17 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1560506926 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1560511752 In the past using the old IIMs system we never heard any feedback from our reporting. I think that the new system is improving]]> 2021-05-26 07:00:26 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1560511752 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1560547488 I clearly remember one incident where a pt who was in a reasonably new high dependency unit died due to receiving a Heparin infusion to treat a PE when they were just Day 1 post craniotomy for evacuation of subdural haemorrhage. The pt was placed on a Heprain infusion with the normal parameters that afternoon, and had passed away the next morning due to an extensive subdural haemorrhage overnight. I was involved in the RCA investigation and I openly and honestly informed the team that the nurses working in this new high intensity unit had not received any additional training, and that it was common for less experienced staff (even casual staff as was the case with this pt) to be allocated to working there because the senior nurses did not feel safe working there and didn't want to be held responsible for adverse events. There was then a large overhaul whereby all staff working in the unit were provided additional, mandatory education opportunities, and the policy was updated to include a minimum nurse to patient ratio of 1:3 instead of the previous 1:4, among other things.]]> 2021-05-26 07:16:53 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1560547488 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1560568477 Despite the numerous IR for pt falls in our neuro ward where there are a lot of confused pts who are impulsive and often ataxic, and the continual recommendations for special 1:1 nursing as a falls prevention strategy, there continues to be a lack of special nurses allocated, and to add to that burden, the ward is often short-staffed meaning that nurses have an additional pt workload in addition to the absence of special nurses for those high falls risk patients who require 1:1 nursing.]]> 2021-05-26 07:24:41 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1560568477 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1560999686 Reporting on increased patient falls lead to the changes of time for frusemide to be given in the morning. Doses charted for 0600 were changed to 0800 due to patients rushing to get out of bed to use the bathroom at a time when the number of staff on the ward was less than during the morning round leading to an increased number of falls.]]> 2021-05-26 11:36:11 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1560999686 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1561002432 I have previously reported on used sharps being left in the medication trolley by a member of staff that was a senior RN. My manager at the time asked me about the incident and said he spoke to the staff member who said they simply forgot to put them in the sharps. To me this was not a good enough response to the incident. 1) because reducing the risk of a sharps injury is a vital part of nursing training, 2) the staff member was a senior nurse and should know very well the safe disposal of sharps and 3) there was nothing done to reduce the risk next time.
It was very disappointing to be the one who was in direct harm and see nothing done as a result of reporting the incident.]]> 2021-05-26 11:37:47 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1561002432 viviennepspeirs https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1561021482 I have been on the receiving end of a patient complaint for how I have dealt with them; and in hindsight I agree with them, as I am brash. However, I have also been unaware of this complaint, with no right of response, because of the way my workplace handled the situation. They dealt with it by appeasement perhaps--I will never know--because the first I heard of it was six months later, well after the issue could have been resolved and I could have apologised. It was told with a list of other small collections of 'sins'. This was my negative reporting that has always irked me. I found it unfair. it gave no chance for my voice, no chance for reconciliation and gave much power to the keeper of the 'secrets' which I believe was unethical.
Vivienne ]]> 2021-05-26 11:47:46 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1561021482 viviennepspeirs https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1561031241 My recent experience of finding an error (administrative paperwork for a drug was different to the script--the two drug names were one line apart) which could have become a medication error on my shift if I had not noticed the handwritten tracking system we use that states the correct drug name. 
This caused me to check and recheck, then after a small pause to write the report using IMS+ so it was known and to prevent it happening again. 
It was positive because it gave me the opportunity to think through solutions, inform the people involved and openly communicate.
It was such a polar experience to my previous employment experience noted in the negative column. It was gratifying; I felt like I was contributing. This is why I believe patient reporting and complaints, plus incident reporting are so important for change; but it must be done with a view to heal and amend, not blame, condemn and revel is someone's discomfort.
Vivienne]]> 2021-05-26 11:52:55 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1561031241 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1562327794 In this incident I was not the one reporting an incident or ongoing incident but another staff member. Last year we were severely understaffed (still are) and administration kept deploying staff (while it was short everywhere it was starting to get ridiculously unsafe) so one of my colleagues put an IMMs report on those who kept deploying staff because there were issues with safety because of the the short staffing. The hostility that happened after and the verbal bashing that nurse received was shocking. That was one of the more negative experiences I have witnessed after an incident was reported. ]]> 2021-05-26 17:28:34 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1562327794 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1568137874 2021-05-28 11:13:31 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1568137874 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1570144259 A new grad disconnected an IV line from a patient. He was receiving glucose because of hypoglycaemia. The line was not reconnected for 6 hours. The patient required a Clinical review. The new grad had followed the (bad) practice on the ward of disconnecting IV line to shower people despite efforts to change the practice on an ad hoc basis. I had discovered what had happened at handover so I reported the incident. I also spoke with the staff involved to advise them that I was making a report but only so that the practice would change and that I understood that she was following a ward practice. I also spoke with the CNE who was charged with looking at the incidents who gave feedback to the whole ward with the relevant policy information. The practice was changed and the new grad was not shamed but learnt from the experience.]]> 2021-05-29 05:01:02 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1570144259 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1570149307 When our entire hospital moved into a new clinical facility, there was an incident with blood not being hung up within the 15minutes from delivery from pathology. It was not returned to pathology and so was wasted. I was involved in the incident and wrote an incident report in the IMS. Following investigation the other nurse in the incident came to me, most distressed by the way that the investigation was handled as she was made to feel that it was her fault. The investigator, a CNE, had not looked at any environmental issues or workloads that we experienced that shift. We had been very stretched and had a number of high risk situations that were occurring all at the one time. There were problems with IV access at the point of hanging the blood, which had been checked prior to calling for the blood to be delivered. The CNE mounted his high horse and told us that we would have to do further education on blood transfusions. After a 20 minute conversation detailing the shift we had endured, and in the context of a new building where everyone was still finding their feet, I was able to make the CNE see how the issue came about and we did not require further education. However, there was a lot of distress caused in an already stressful situation and we received no further feedback.]]> 2021-05-29 05:09:00 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1570149307 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1570227182 One of my staff put in an incident report about a patients mother who was abusive to her across the phone as she wanted a script for a medication after she had lest an email requesting script after an hour the staff member had not responded to the script request and then call the staff member abusing her for not responding to her(patient) email.. The staff member was very upset by the incident.
When I investigated the situation I was able to identify that the patients request was not urgent and that there are practices in place for her to contact the team via various options ie email, phone and voit phone so if the patient's family identified that their need was urgent they had access to the staff member to escalate their request. Further to this the request occurred on a busy clinic day which doesn't allow for the staff member to check emails as frequently as hourly across the day. A new staff member has been added to clinic to support the clinical needs of the clinic but to also support such admin tasks of checking emails etc.]]> 2021-05-29 07:25:23 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1570227182 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1571301701 In 2017, a trend in infrequent staff incident reports on administration of IV Amiodarone loading and maintenance doses over 18 months was identified by the newly formed Medication Incident Review Workgroup in my ICU. As a result the administration procedure was reviewed and updted. The new guidelines were developed and provided to staff with education; electronic prescribing parameters were set into the eMR and the 'Guard Rails ' on the infusion pumps were amended to reflect the new prescription. Subsequent review of the incident reports have confirmed a significant reduction in Amiodarone prescription and administration errors.]]> 2021-05-30 07:54:53 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1571301701 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1571308562 I have been on both sides of incident reporting, as a reporter and an investigator. I have noticed both good and bad approaches to IR and what makes an investigation either +ve or -ve. I think that an attitude of no blame and truth telling for patient, staff and service safety and transparency is the most important aspects to a successful IR system and culture of accountability. ]]> 2021-05-30 08:01:29 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1571308562 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1572252843 A young post graduate nurse who is demonstrating excellent nursing skills at her stage of nursing, experienced a negative episode which has instigated her resignation from our facility.
A patient asked the nurse to put in a complaint on their behalf about another staffs manner and attitude which upset them immensely.
So the nurse did so on behalf of the patient, the HSM approached the nurse in front of several other staff members in the staff room and in front of all the staff told her she should not have put in the complaint as now he had to deal with it in a formal manner not just speak to the the nurse being complained about. The tone and manner used by the HSM was also very disrespectful to the young nurse along with those staff members listening/witnessing the incident.]]> 2021-05-31 00:40:15 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1572252843 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1572714861 2021-05-31 04:38:45 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1572714861 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1573242717 A positive IIMS result was when we initiated a new way of working when checking breast milk feeds into the fridge. To minimise breast milk administration errors, two RNs check the breast milks in each patient tub at the end of the night shift, at the end of the day shift and at milk delivery time. This has reduced errors where milk was in the wrong patient tray, but unfortunately this positive process came about from breast milk errors where the wrong milk was given to the wrong baby. ]]> 2021-05-31 09:22:00 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1573242717 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1581856995 I work in a busy CCU and recently we have had high staff turnovers]]> 2021-06-03 07:11:18 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1581856995 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1582178225 I worked in the UK where there was a big culture of blame associated with incident reporting. The manager would send an email to the whole staff asking "who was responsible for the incident". It ultimately meant that people didn't report incidents when they occurred.

]]> 2021-06-03 11:04:33 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1582178225 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1582179234 My current ward environment has a great culture about incident reporting and have started reporting lots of near misses, as well as incidents particularly with medication errors. This has resulted in a quality improvement project into medication safety on the ward to prevent medication errors. ]]> 2021-06-03 11:05:37 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1582179234 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1586927804 2021-06-05 13:16:54 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1586927804 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1586930441 2021-06-05 13:19:29 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1586930441 https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1604906645 2021-06-14 12:11:57 UTC https://padlet.com/postgraduate_futures/d6j9jm4sd6ryq596/wish/1604906645