Learning from error
Make sure this blog is only 1600 words EXCLUDING references, tables, appendices and pictures.
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).
