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Dare to Share

Dare to Share. Learning from experience: a practitioner’s reflection. Dare to Share. Facts and Figures Experience of Adverse Incidents Observations/ Reflections Questions. Facts and Figures. National Confidential Inquiry Safety First Document 2001 Avoidable Deaths Document 2006.

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Dare to Share

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  1. Dare to Share Learning from experience: a practitioner’s reflection

  2. Dare to Share • Facts and Figures • Experience of Adverse Incidents • Observations/ Reflections • Questions

  3. Facts and Figures • National Confidential Inquiry • Safety First Document 2001 • Avoidable Deaths Document 2006

  4. Inpatient suicides: trends over time

  5. Inpatient suicides: trends over time 1997 1295 222 (17) 2004 1396 155 (11)

  6. Facts and Figures • Some success with “priority groups” • Inpatients • Non-compliance • But……..

  7. Facts and Figures • 1300 p.a (NCI April 2000-Dec 2004) • No real change in post-discharge period • 49% in contact week before death • 19% in contact 24hrs before death • 86% thought low risk at last contact

  8. Facts and Figures • 233 (18%) p.a “preventable” (NCI) • For inpatients 28% “preventable” • AWOL, non-routine obs, MHA 41% “preventable” • Should wards be 100%?

  9. Experience of Adverse Incidents • 1. Training Course • 2. Panel member on PIR • 3. Reflective practice reviews • 4. Implementation Action Plans • 5. Interviewed by PIR panel

  10. Training Course • Intensive • Hard Work • Grounding in Root Cause Analysis (RCA) • Contribute to PIR

  11. PIR • Development • Resource intensive • Detailed investigation • Problem of hindsight • Individual versus process issues • Some basic deficiencies • Importance of documentation

  12. PIR • Section 17 leave not clear • No explanation of changes to obs levels • Communication with others • Information/concerns of carers/relatives

  13. Action Plans • Recommendations from PIR • AMH action plan • Problems with recommendations • Danger of too many • Practicality of implementation

  14. Patient Suicide • Age 51 • Known since 1998 • History of schizophrenia • Long inpatient stay • Died in Nursing Home

  15. Aware of vulnerability • Keep accurate up-to-date records • Positive Risk Management

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