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Significant Events Shirley Moon Clinical Governance Facilitator 14th September 2005 NPSA – Reported incident types in general practice INCIDENT TYPE NUMBER % Patient accident 27 6.2 Medication 91 20.8 Documentation (including records, identification) 104 23.7 Consent, communication, confidentiality 70 16.0 Access, admission, transfer, discharge 44 10.0 Clinical assessment (including diagnosis, scans, tests) 40 9.1 Infrastructure (including staffing, facilities, environment) 12 2.7 Medical device/equipment 7 1.6 Treatment, procedure 12 2.7 Implementation of care and ongoing monitoring/review 5 1.1 Disruptive, aggressive behaviour 2 0.5 Infection control 1 0.2 Patient abuse (by staff/third party) 2 0.5 Other 21 4.8 TOTAL 438 100.0 PCT Incident Database 54 Medication errors, including 18 incorrect drug and 11 incorrect dose. (Reported by GPs, Pharmacists and Hospital Pharmacy.) Need to double check prescriptions. 13 Documentation errors and 77 Communication incidents, including 29 between healthcare staff (e.g. messages not passed on, lack of communication between primary/secondary care) and 22 between staff and patients (e.g. patients getting wrong results). Need to check Admin procedures. 2 educational needs highlighted (JK progressing) – re: X-ray procedures and spinal cord compression. NPSA - Anticoagulants The National Reporting and Learning System database includes 311 incidents involving anticoagulants, including 2 deaths. 600 negligence claims as a result of harm or near harm associated with the use of anticoagulants. 120 cases resulted in death. 223 cases reported to the MDU, including 60 deaths reported from general practice. Main causes for fatal incidents were inadequate laboratory monitoring and clinically significant drug interactions usually involving pain killers. DO YOUR SEAs MEET THE QOF REQUIREMENTS? CHECK GUIDANCE IN ANNEX E