Accreditation practice pointer: clinical risk management system improvements
QI3.1 B Our practice team makes improvements to our clinical risk management systems in order to prevent near misses and adverse events in clinical care.
RACGP Standards for general practice
General Practice must have a process of safeguarding against near misses and adverse events. All actions taken in response to events must be recorded on the incident and event register. The benefits of this process are twofold: ensuring patient safety and reducing the risk of medico-legal action.
To reduce near misses and adverse events, general practices can:
establish a system so that practitioners talk to trusted peers and supervisors for advice
use a formal process of discussing within the practice what went wrong and how to reduce the likelihood of it happening again
use structured techniques to analyse the causes of near misses and adverse events to reduce the likelihood of recurrence
establish a system so that members of the practice team know how and to whom to report a near miss or adverse event, and that they can do so without fear of recrimination
keep copies of the practice’s risk or critical incident register
monitor the effectiveness of systems and processes for infection prevention and control (e.g. standard precautions)
ensure that relevant public health notifications are distributed to all practice team members in a timely manner.
implement a clinical governance framework to help achieve a balance of ‘find it’, ‘fix it’ and ‘confirm it’ functions in order to improve the quality and safety of care
find it – use tools such as clinical audits and performance indicators to identify where quality improvement programs could improve the quality of care and patient health outcomes
fix it – after identifying where improvements can be made, implement strategies to address the issue
confirm it – measure the outcomes of the improvement using an effective evaluation process.
Practices might also consider asking their medical defence insurer check and approve their process for recording and responding to near misses and adverse events.