Scenarios: Team Reflection

Two events-faulty equipment and a near miss-show how candour and learning work together to strengthen systems without shaming people. [5]
Scenario 7 - Faulty equipment
Scenario 8 - Near miss
Accountability and verification (for both scenarios)
- Accountability details to record: who led patient contact; what remedial actions occurred; when supplier or engineering steps were taken; why selected controls are expected to reduce recurrence. [2] [1]
References (numbered in text)
- The professional duty of candour — General Optical Council Find (opens in a new tab)
- Regulation 20: Duty of candour — Care Quality Commission (CQC) (page updated 2024) Find (opens in a new tab)
- Openness and honesty when things go wrong: The professional duty of candour — General Medical Council (GMC) (published 2015) Find (opens in a new tab)
- Vigilance reporting requirements — Medicines and Healthcare products Regulatory Agency (MHRA) / GOV.UK Find (opens in a new tab)
- Patient Safety Incident Response Framework (PSIRF) — NHS England (2024) Find (opens in a new tab)
- Added value of double reading in diagnostic radiology, a systematic review — Håkan Geijer; Insights into Imaging (2018) Find (opens in a new tab)
- Effect of Bar-code Technology on the Incidence of Medication Dispensing Errors and Potential Adverse Drug Events in a Hospital Pharmacy — Eric G Poon et al.; AMIA Annu Symp Proc (2005) Find (opens in a new tab)
- Clinical audit: a guide for NHS Boards and partners — Healthcare Quality Improvement Partnership (HQIP) (2021) Find (opens in a new tab)
- Early resolution and providing a remedy (good complaint handling guidance) — Parliamentary and Health Service Ombudsman (PHSO) Find (opens in a new tab)
References are included to demonstrate that all the content in this course is rigorously evidence-based, and has been prepared using trusted and authoritative sources.
They also serve as starting points for further reading and deeper exploration at your own pace.

