WK 8

• patients who experience an adverse event need: (C)ACAO

  (C)Apology

  Analysis of incident

  Change to prevent recurrence

  Advice about necessary treatment

  Ongoing support
• Clinicians involved in an adverse event need:

  Support

  Advice

  Recognition of systems nature of adverse events

  Sense of Security about investigation and improvement processes
• Clinical Governance is about

  Accountability and creating an environment for clinical excellence