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Contact magazine september


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Contact magazine september

  1. 1. CONTACT Autumn 2010 Volume 24 Number 3 A helping hand for members of the British Chiropractic Association NEWS • REPORTS • BUSINESS • FEATURES • DIARY • CLASSIFIEDS CPiRLS: Towards a reporting culture Planning for the unexpected Recruiting right
  2. 2. 26 Contact Autumn 2010 • How often have you encountered this type of incident in the past? • What is the likelihood that your actions/ inactions were responsible? • Further information (voluntary)* When you open a reporting form, it remains active for one hour; it would not be good practice for it to remain open indefinitely on a secure site.This means you must submit the form within that time to avoid your entry being lost.With this in mind, it may be a good idea to plan or draft a particularly detailed case before starting to enter it. A draft on your computer can be cut and pasted into the relevant fields. Learning from incident reporting The principle of CPiRLS is that it provides an opportunity for all chiropractors to learn from collective experiences. Regular visits to the site enable you to keep abreast of recent 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 HaymoThiel 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! The use of the word‘safety’, in the context of chiropractic incident reporting, is possibly misleading.There is no suggestion that chiropractic is unsafe.The term should be taken in its widest sense, to encompass the concepts of risk and injury and CPiRLS should be viewed as a means of minimising these components of safety. The CPiRLS website provides a trigger list (available once you log in) which helps you to identify the types of incidents that may be worth reporting. It is true that some of the incidents listed may appear insignificant and, to some extent, fairly routine, for example, post-treatment soreness.There is, of course, no expectation that you would report every case of post-treatment soreness however, if a patient had an unusually acute reaction (i.e. something out of the ordinary that prompted you to mention it to a colleague in conversation), then why not mention it to the national chiropractic community, particularly if you felt you learned something from what happened? Producing an incident report First and foremost it must be emphasized that CPiRLS is a completely anonymised process. The system only actually requires basic information, with an emphasis on what happened. The main reporting form has the following fields, most of which require a simple choice from a pull-down menu. Only those five fields marked with an asterix below require text input from the reporter: • Patient’s age and gender • Where the incident happened • Category of incident • What happened?* • Why and how did it happen?* • Describe the actions taken* • Key words to describe the incident* • Was the patient harmed? • Could the incident have been avoided? Special Interest
  3. 3. Contact Autumn 2010 27 Is there a time limit for reporting an incident? The learning value of any incident that had an impact on you and your practice does not deplete over time.You should not underestimate the potential importance of sharing incidents months, or even years, after they occur. reports and to share comments with other visitors. Some clinics are now basing regular clinic meetings on a review of the incidents reported on CPiRLS. For example, one clinic Principal commented: “Withinourpractice,thechiropractorsmeet everysixweekstoreviewchallengingcases andanyincidentsthathaveoccurredor beenavoidedbygoodpracticeanddecide ifanyrequirereporting.Aspartofour reflectivepractice,wealsolookattheCPiRLS reportsthathavebeensubmittedtosee whetherwecanlearnfromtheseincidents. IamfindingthatCPiRLSisanexcellenttool forpromotingreflectivepracticeatmyclinic. Althoughithastakenalongtimetowork outhowbesttogetallpractitionersaware ofincidentreportingandbeingpro-activein thisrespect,Ithinkwearefinallythere. In a recent study of the culture of safety among UK chiropractors (Finch et al, 2010), there was a strong indication that awareness of the importance and value of incident reporting is growing and that lessons are being learned locally, through clinic initiatives of the type outlined above. However, it is clear that this growing awareness has not yet been fully translated into widespread national reporting via CPiRLS although, hopefully, this is now changing. The CPiRLS Implementation Group has published two Safer Practice Notices in response to minor trends identified among the reports submitted to date.These serve to provide guidance in the management of the type of incidents in question should they be encountered again. Additional notices will be produced as further trends arise. Frequently asked questions What is an incident? CPiRLS defines a reportable incident as any type of patient safety event, error, accident or deviation from the norm that actually happened, nearly happened (near miss) or has the potential to happen.This is regardless of whether it is considered minor or major, results in significant patient harm or leads to a patient complaint. How do I access CPiRLS? The full features of are only available to registered chiropractors through the use of a generic username and password. These can be obtained from the professional associations and the College of Chiropractors. References Cunliffe C, Johnson IJ, Selby J (2009) Safety incidents, treatment complications and reactions recorded in a student teaqching clinic: a retrospective analysis. Proceedingsof theAssociationofChiropracticCollegesResearch AgendaConference(ACC-RAC). Finch RP, Heale GS, JayTC (2010) Culture of safety among UK chiropractors before and after the launch of online patient safety incident reporting and learning. ClinicalChiropractic 13, 172-173. Thiel HW, Bolton JE (2006)The reporting of patient safety incidents – first experiences with the chiropractic reporting and learning system (CRLS): a pilot study. ClinicalChiropractic 9, 139-149. @ Special Interest