Incident Review Report | Original 18 MERIT Items | Guide for Assessors |
---|---|---|
Personal Learning | Factor 1: Personal Characteristics of QI | Examples of expected standard |
1. What do you think were the contributing factors for the doctors involved in this incident? | • Quality of reflection on doctors practice • Sufficient details to delineate contributing factors | Demonstrates an understanding of the situation and can discuss the contributory factors within their incident and discusses in detail. |
2. What could the doctors do to avoid similar problems in the future? | • Relevant new behaviours were proposed | Communicate with the team, patient, family Take a break, eat Find a more suitable environment to do task Consult a senior, Use protocols |
3. What personal learning needs have you identified from this incident review? | • Doctor questioned their readiness to practice. • Multiple options for personal change were considered. • Contributing personal factors were identified | Characteristics – both technical and non-technical skills – readiness to practice i.e. lateness, attention to detail, memory Use of checklists, memory aids, asking for help |
4. How will you meet these learning needs? | • Next steps towards personal change were identified. | Identifies specific ways to change |
Personal Learning Score | Mark from 1 to 7: A score of 6 or 7 would include examples of: situational awareness, specific and timed learning objectives. | |
Changes required to the system | Factor 2: System characteristics of QI | Examples |
1. What do you think were the systems factors that contributed to this incident? Systems factors includes: the characteristics of the team and clinical setting where the incident took place, in addition to the organisation. | • Quality of reflection on the institution or wider health care system. • Current institutional practice or system was questioned • Contributing system factors were identified. | Culture – hierarchy structure, team work, communication between teams, different staff teams Environment e.g. noisy, lack of space to work cramped conditions, continually interrupted |
2. What changes to the system might avoid similar problems in the future | • Relevant changes to the system were proposed • Next steps towards system change were identified | Use of multiprofessional handover, safety briefings, medicines reconciliation e.g. use of more than one source to confirm medications. Effective communication |
3. What tests could be done to see if the changes might work? | • Multiple options for system change were considered | Testing any of the ideas above. |
System Characteristics Score | Mark from 1 to 7: A score of 6 or 7 would include examples of changes to doctors and nurses working and small tests of change | |
Why it is an important incident | Factor 3: Problem of Merit | Examples |
1. What was the impact of this incident on the patient? | • Event was patient centred | Patient had an increased length of stay, patient had to undergo other investigations, patient developed infection, DVT, Investigations/theatre cancelled or delayed |
2. How likely is it that similar incidents could affect other patients? | • Potential for event to affect other patients | Evidence of Impact of this incident on other patients |
3. What is the worst that could happen to a patient because of an incident like this? | • Event could cause negative clinical impact • Overall problem of merit | Recognising the worst consequences from this incident e.g. The patient could have lost the wrong leg, required renal replacement, patient had to be admitted to HDU/ICU. |
4. Event was evidence based in description | • Quality gap established from standards and guidelines (local or national) | Evidence of further reading, highlights local /national guidelines, relates other initiatives to incident, examples of good practice e.g. use of new folder for current admission. |
Incident Importance Score | Mark from 1 to 7: A score of 6 or 7 would include examples of patient involvement and of negative impact on patient and public confidence in the NHS or on patient experience | |
Overall Score | Mark from 1 to 7 | |
*Guide to scoring (1–7) | Description | |
1–2 | Concern | |
3–5 | Satisfactory | |
6–7 | Highly satisfactory |