Keynote 3: Prevention of critical incidents – an issue for different disciplines

Abstract:
Critical incidents may relate to issues of communication, knowledge, culture, relationships, emotions or beliefs. In the clinical setting, critical incidents may comprise medical emergencies, unusual conditions and further difficult-to-handle situations. The delivery of high quality patient care is a sophisticated process that strongly depends on team work and in many cases involves complex organisations and high technology methods. The level of quality of care and the occurrence of adverse events and critical incidents is influenced by a variety of different factors. Analysis of adverse events and critical incidents is therefore key factor to understand causes and underlying reasons, deduce prevention measures, implement improvements and so minimize the probability of reoccurrence.

High-risk industries, e.g. aviation, oil or nuclear power industry, realised the importance of this much earlier than within healthcare. The investigation of accidents, learning from incidents and the analysis of near misses are central procedures of an implemented safety and risk management culture. Thinking outside the box! In the last decade, relevant literature and evidence on risk reporting, analysis and prevention in the healthcare area has been growing, and healthcare professionals took inspiration from other disciplines.

Hospital pharmacists recognise the prevention of critical incidents as a high-priority issue on their agenda, as pharmacotherapy and the medication process are error-prone and complex.

Teaching Goals:

• to introduce and describe the concept of critical incident prevention in healthcare, with a focus on the medication process and the hospital pharmacists’ role
• to comment on differences of critical incident prevention in other high-risk industries, illustrating chances for professional advancement
• to discuss the role for hospital pharmacists in this concept and propose further engagement.

Learning Objectives:

After the presentation the participant should

• be familiar with key issues of critical incident prevention across different disciplines
• be able to state the most important roles for hospital pharmacists regarding critical incident prevention