Termez branch of Tashkent Medical Academy Medical faculty 1st stage 109-b group student Subkhanov Ruslan Independent work on foreign languages

PERSON RESPONSIBLE FOR THE IMMEDIATE MANAGEMENT OF THE INCIDENT The person responsible for the immediate management of the incident (e.g. the nurse in charge of the ward at the time an incident occurs), should undertake an immediate assessment of the situation, in order to determine any immediate treatment and/or ongoing care needs of the affected person, and/or the extent of any loss/damage to property and any other immediate action required (e.g. removal and isolation of faulty equipment). The situation/scene should be made safe.

ROOT CAUSE ANALYSIS Root Cause Analysis’ is a structured investigation process that aims to assist in the identification or the root or underlying cause(s) of a particular event or problem by determining WHY the failure occurred and the actions necessary to prevent or minimize the risk of recurrence. A ‘Root Cause’ is a failure in a process that, if eliminated, would prevent an adverse incident occurring. Training for the relevant staff on incident grading/investigation and root cause analysis will be provided as part of the risk management training programme.

FAIR BLAME CULTURE In an organization as large and complex as the Hospital, things will sometimes go wrong. The wrong assessment should not be one of blame and retribution, but of learning,a drive to reduce risk for future patients and staff. Blame cannot, and should not, be attributed to individual health care professionals. Identifying and addressing dysfunctional systems is, therefore, the key to reduce the risk of harm for many patients and staff through incident form.

It is understood that fear of disciplinary action and subsequent sanctions may discourage the staff from reporting incidents, therefore,continues to be developed within a culture of ‘fair blame’. The Management approach following incidents will therefore focus on ‘what went wrong, and not who went wrong’.