The Question:

Post a reaction to the following student Post . What were good ideas that you would like to adopt at

your organization?

What most surprised you about his post and why?

No citations required.

student Post:

system is voluntary, subjective. It is mainly initated by nurses to report an incident. In the Operating

room, any situation that deviates from the normal path of events is reported in the DATIX, the

handler and the reporter of the event are both identified, the handler is required to write his/her view

on the event, then the final report is handled by an invistigation team at the quality department for

further action. As far as I am aware, this system does not allow for any information to patients/family

on the event. Any support to the staff is handled individually through the person’s department.

This system has a plenty of room for improvement. The main drawback is subjectivity, what to be

considered an adverse event worthy of report or not. The sytem ought to be objective, ensuring

anonymity and protecting both the reporter and the handler. Also, there should be an agreement of

what is worthy of being reported and what not. A patient refused surgery after arriving to the OR was

reported by a nurse in the DATIX, and handled against the Anesthesiologist at one instance. The

matter escalated further and diffused at the quality committee. I believe that one person in each

department should be responsible for reporting adverse events, scored according to severity and harm

caused to the patient, the system should not be left to a personal point of view. Informing patients,

families of an adverse event to the patient should have a clear defined mechanism, handled seperatly

through patient’s affairs and the patient’s most responsible physician handling his/her care.

Supporting healthcare workers during an event against them should also be clearly defined and

handled with care. The main aim of every healthcare worker is not to cause harm, cares for the

patient to the best of his/her knowledge and experties. The current atmosphere unfortunatly punishes

a worker who performs or is involved in an adverse event. The case should be referred to staff affairs

coucellers who assist staff during this event.

At the level of the Ministry of Health, any adverse event is reported by the patient in the form of a

complain to the Ministry who forms a committee to look at the complain, the committee may include

people with no medical or healthcare background, if an error is identified and harm is caused to the

patient the staff is punished and the patient is compensated.”

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