An Incident of Poor Practice: Focusing on Identifying and Responding to an Error

This is a report (1500 words) on an incident of poor practice, focusing on identifying and
responding to an error or to poor practice.
This report could be structured like this:
1. Introduction. Students should outline what this report will cover (150 words)
2. Students should analyse the role of individuals, teams, employers and professional,
statutory and regulatory bodies in the delivery of safe and effective health and social
care (400 words)
3. Students should link and reference a statement of event (attached as an appendix)
on an incident of poor practice in simulation. The focus is on identifying, reporting
and responding to an error or poor practice. Links should be made to service
improvement, clinical governance and to your specific professional standards (500
words)
4. Students should reflect on their contribution to safe and effective person centred
care - this section can be written in the first person (300 words)
5. Conclusion - do not introduce new ideas in this section (150 words)
You are able to choose what situation/scenario you write your report on - this is to keep the
assessment real to practice, as health professionals often have to respond to an
investigation and write a report days/weeks or months after an event from the notes that
they had written when delivering the care.
As part of this assignment you are required to complete a ‘Statement of Events’. A template
for this has been created and will be uploaded to the Moodle site. This replicates an in
hospital incident report and can be used to create your own statement of events. The aim of
this is to support your 1500-word report and includes relevant information on how to
complete it correctly. The ‘Description’ section should be an objective and factual account of
what happened during the episode of poor practice.
This report must be supported by relevant references. Your references could include the
professional Codes, NHS Constitution and any other key information relating to the
domains.
Reporting an incident
Who does the incident affect?
• Patient (In-patient, Out-patient, Day Case Patient)
• Staff (Trust Employee, Volunteers, Students, Agency/Locum)
• Visitor/Contractor/Member of the Public
• The Organisation (e.g. IT, Information Governance, Services, Premises)
Person(s) Affected:
• Type (choose from list above e.g. In-Patient):
• Title:
• Patient/staff number:
• Gender:
• Ethnicity:
• Was the person injured in the incident? Yes/No
NB: In clinical practice, the reporter would be expected to provide the full name of the person(s) affected. However, you are not expected to for the purposes of this assignment.
Details of the incident
• Site (This is where the incident occurred – e.g. PHT, Out Patient Centre):
• Division (This is the division in which the incident occurred e.g. Medical Division):
• Type of location (This is the generic type of location where the incident occurred, e.g. ward, corridor, car park):
• Exact location (This is the specific location where the incident occurred, e.g. A&E, Maternity Ward, Pharmacy, etc.):
NB: In clinical practice, the reporter would need to enter in the Incident date (dd/MM/yyyy) and Incident time (hh:mm), however for the purposes of this assignment you will not be expected to do this.
Description:
• Category of incident (e.g. Blood and Blood products incidents / Direct Care (Patient Safety Incident) / Fall – Patient Slip, Trip or Fall)
• Only enter facts, not opinions, and avoid abbreviations.
• DO NOT ENTER THE nameS OF PEOPLE (Use job titles and roles instead – e.g. Patient, Nurse, etc.).
• Relate the facts from the beginning and keep them in chronological order, giving precise dates and times.
• Don’t speculate, elaborate or exaggerate, or use emotional language.
• Action taken (Enter action taken at the time of the incident):
NB: In clinical practice, the reporter of an incident usually has to risk grade which refers to the likelihood of recurrence. You will not be required to complete this for this assignment.
Mandatory Information:
• Was anyone else involved in the incident? Yes/No (e.g. witness, member of staff, etc.)
NB: In clinical practice, if the answer to this was ‘yes’, the reporter would need to add type of person affected, their title, forename(s), surname, patient/staff number, gender and ethnicity. You are not expected to do this for the purpose of this assignment.
• Was the person injured in the incident? Yes/No
NB: In clinical practice, the reporter usually has the opportunity to attach any relevant documentation to the incident form, such as a witness statement or photographic evidence, etc. You will not be required to complete this for this assignment.
This is the questionnaire that needs to be filled too
Thanks