Anaesthetists Handbook - MEDICAL EDUCATION at University ...

Clinical adverse event reportingClinical adverse event reporting[Appraised by Dr Keith Clayton and Dr Edwin Borman, January 2010]A clinical adverse event is an untoward event that led to harm, or ifallowed to progress could have led to harm. Clinical adverse eventreporting is an essential element of clinical governance, helping toimprove the quality of clinical services, and UHCW has such asystem in operation.Forms to report these adverse events are located in each theatresuite, intensive care unit and delivery suite. Ask the sister in charge.All clinical adverse events should be reported on these forms. Whencompleted, place in the CAE box in the Anaesthesia Office(forms relating to maternity care should be submitted throughlabour ward).If appropriate, action will be taken to prevent these incidents fromhappening again. In the past, significant improvements in patientsafety have been implemented as a direct result of reported clinicaladverse events, so you are encouraged to report any such events.Clinical adverse events are discussed at the monthly audit meetingsfor educational and information purposes. The identity of theanaesthetist involved is not made public unless they choose toidentify themselves.Clinical adverse events are grouped into three broad categories.Examples of the sort of events that you should report are givenbelow. Please remember that these examples are not exhaustive andyou should report any incident that you feel falls within the basicdefinition above.Anything which has or, if uncorrected could, put at risk thesafety and well being of the patient.Human• Cardiopulmonary arrest.• Airway obstruction.Anaesthetists Handbook January 2010 91