Order Description
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?

student Post:

”
In KFMC, the main system for reporting medical errors or adverse events is the DATIX system. The 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.”