‘rights’ will not only avoid unnecessary judging
and blaming of the victims, but also help the
victim to participate in the analysis of the
adverse event. An ideal approach for the
secondary victim will help determine additional
support that should be provided in addition
to the local support from work partners
(including professional, psychological or even
legal support).
Analysing a severe adverse event
Simultaneously to victim support and attention,
the institutional response should include
a thorough investigation of what had just
happened, together with an appropriate analysis.
Once a serious adverse event has been identified, 7
all the information surrounding it must be
gathered, ordered chronologically, and analysed
in order to understand what happened and why
it happened. The conclusions drawn from the
analysis should provide the tools to prevent
similar events from happening in the future.
Analysing the main or root cause responsible
for a severe adverse event can be a very difficult
task, as many of these events usually have
a multifactoral aetiology. The London Protocol is
a valuable tool at the moment of conducting this
analysis, as it designed to investigate and develop
contributing factors to an adverse event in seven
different areas. The factors considered by the
London Protocol are: patient; task and
technology; staff; team; work environmental;
organisational and management; institutional
context. Determining contributing factors in
a organised way allows a complete analysis,
considering the different aspects that might be
involved in the event, and facilitating the
provision of solutions; as they can be approached
individually for each involved factor and
ultimately in a global perspective.
The analysis should ideally start within
72 hours of the event and should include analysis
of every piece of evidence in the setting of the
event and the clinical files, as well as what can be
gathered from interviewing the persons involved.
Additional scientific evidence from similar cases
might also help in this phase.
Achieving resolution
Resolution is only reached after completing the
phases mentioned before, and it is met by the
actions directed to fulfill the needs created after
the adverse event in three main groups: patient
and family, professionals, and the institution
itself. Solutions should come not only from highly
ranked individuals in the institution, but might
also need to come from legal experts or insurance
companies in certain situations.
It is important to understand the final
objective after completing the previous steps is
re-establishing trust for the victims and also for
the institution. The three basic pillars to achieve
this are: 1) providing effective apologies to the
victims; 2) quick and fair compensation for the
damage produced; 3) institutional compromise
for improvement.
The final thought once resolution has been
achieved is that every process must constitute an
example, and strive to reduce or ideally abolish
the probability of a given serious adverse event
ever happening again.
203
HHE 2018 | hospitalhealthcare.com
References
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professionals/quality-patient-
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resources/candor/introduction.
html (accessed July 2018).
3 Disclosure of adverse events
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muhealth.org/about-us/quality-
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clinical-effectiveness/foryou
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(accessed July 2018).
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