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Contact magazine september






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Contact magazine september Contact magazine september Document Transcript

  • Autumn 2010 Volume 24 Number 3 CONTACT A helping hand for members of the British Chiropractic Association Planning for the unexpected Recruiting right CPiRLS: Towards a reporting culture NEWS • REPORTS • BUSINESS • FEATURES • DIARY • CLASSIFIEDS
  • Special Interest CPiRLS: Towards a reporting culture The UK’s national online Chiropractic Patient Incident Reporting and Learning System (CPiRLS) was launched in May 2009. In the 15 months since its launch, submission rates have been low - around two incidents per month. Here, Rob Finch, Chief Executive of the College of Chiropractors, writes on why the full benefits of this system can only be realised with more use and participation. T he College of Chiropractors administers CPiRLS on behalf of the pan-professional team that developed it. The system is based on the pioneering work of Haymo Thiel and the two former paper-based incident reporting systems: CRLS (Thiel et al, 2006) and PiRLS (Cunliffe et al, 2009). An Implementation Group comprising clinicians, academics and educationalists, monitors the use of CPiRLS and adds relevant resources to the site. What you can report Any occurrence that has made you think about an actual, probable or potential impact on patient safety can be reported. If this occurrence led you to discuss the case with colleagues, to consider changes to your practice and/or to personally reflect in a non-routine manner, then it is probably worth reporting. If in doubt, report! if you felt you learned something from what • How often have you encountered this type The use of the word ‘safety’, in the context happened? of incident in the past? of chiropractic incident reporting, is possibly • What is the likelihood that your actions/ misleading. There is no suggestion that Producing an incident report inactions were responsible? chiropractic is unsafe. The term should be • Further information (voluntary)* taken in its widest sense, to encompass the First and foremost it must be emphasized that concepts of risk and injury and CPiRLS should CPiRLS is a completely anonymised process. When you open a reporting form, it remains be viewed as a means of minimising these The system only actually requires basic active for one hour; it would not be good components of safety. information, with an emphasis on what practice for it to remain open indefinitely on The CPiRLS website provides a trigger list happened. The main reporting form has a secure site. This means you must submit (available once you log in) which helps you the following fields, most of which require the form within that time to avoid your entry to identify the types of incidents that may be a simple choice from a pull-down menu. being lost. With this in mind, it may be a good worth reporting. It is true that some of the Only those five fields marked with an asterix idea to plan or draft a particularly detailed incidents listed may appear insignificant and, below require text input from the reporter: case before starting to enter it. A draft on your to some extent, fairly routine, for example, • Patient’s age and gender computer can be cut and pasted into the post-treatment soreness. There is, of course, • Where the incident happened relevant fields. no expectation that you would report every • Category of incident case of post-treatment soreness however, • What happened?* Learning from incident if a patient had an unusually acute reaction • Why and how did it happen?* reporting (i.e. something out of the ordinary that • Describe the actions taken* The principle of CPiRLS is that it provides prompted you to mention it to a colleague in • Key words to describe the incident* an opportunity for all chiropractors to learn conversation), then why not mention it to the • Was the patient harmed? from collective experiences. Regular visits to national chiropractic community, particularly • Could the incident have been avoided? the site enable you to keep abreast of recent 26 Contact Autumn 2010
  • Special Interest reports and to share comments with other been fully translated into widespread national Is there a time limit for reporting an visitors. Some clinics are now basing regular reporting via CPiRLS although, hopefully, this incident? clinic meetings on a review of the incidents is now changing. The learning value of any incident that reported on CPiRLS. For example, one clinic The CPiRLS Implementation Group has had an impact on you and your practice Principal commented: published two Safer Practice Notices in does not deplete over time. You should not response to minor trends identified among underestimate the potential importance of “Within our practice, the chiropractors meet the reports submitted to date. These serve to sharing incidents months, or even years, after every six weeks to review challenging cases provide guidance in the management of the they occur. and any incidents that have occurred or type of incidents in question should they be been avoided by good practice and decide encountered again. Additional notices will be if any require reporting. As part of our produced as further trends arise. References reflective practice, we also look at the CPiRLS Cunliffe C, Johnson IJ, Selby J (2009) Safety reports that have been submitted to see Frequently asked questions incidents, treatment complications and whether we can learn from these incidents. What is an incident? reactions recorded in a student teaqching I am finding that CPiRLS is an excellent tool CPiRLS defines a reportable incident as any clinic: a retrospective analysis. Proceedings of for promoting reflective practice at my clinic. type of patient safety event, error, accident the Association of Chiropractic Colleges Research Although it has taken a long time to work or deviation from the norm that actually Agenda Conference (ACC-RAC). out how best to get all practitioners aware happened, nearly happened (near miss) or of incident reporting and being pro-active in has the potential to happen. This is regardless Finch RP, Heale GS, Jay TC (2010) Culture of safety this respect, I think we are finally there. of whether it is considered minor or major, among UK chiropractors before and after results in significant patient harm or leads to a the launch of online patient safety incident In a recent study of the culture of safety patient complaint. reporting and learning. Clinical Chiropractic 13, among UK chiropractors (Finch et al, 2010), 172-173. there was a strong indication that awareness How do I access CPiRLS? Thiel HW, Bolton JE (2006) The reporting of of the importance and value of incident The full features of www.cpirls.org are only patient safety incidents – first experiences with reporting is growing and that lessons are available to registered chiropractors through the chiropractic reporting and learning system being learned locally, through clinic initiatives the use of a generic username and password. (CRLS): a pilot study. Clinical Chiropractic 9, of the type outlined above. However, it is These can be obtained from the professional 139-149. clear that this growing awareness has not yet associations and the College of Chiropractors. @ Contact Autumn 2010 27