How patient safety incidents evolve

The following scenarios present fictionalised accounts or incidents that are based on events that happened to real patients. The names and locations have been changed to protect patient confidentiality, and the dialogue developed to support the scenarios is fictional. The core events underpinning the scenarios, however, are real.

An instruction graphic is provided to help you navigate through the scenarios. The idea of the scenarios is to help you appreciate how the great majority of patient safety incidents are not due to one catastrophic error, rather they are the end result of a series of small errors or omissions along the patient journey that build and escalate to become a poor patient experience and outcome.  There are a lot of aspects in these scenarios you can interact with so it is well worth spending a few minutes to master the 'controls' so you will get the best learning experience from each scenario. It is also important to work through each scenario from the first to the last slide when using the 'incident flag' functionality as you won't be able to see your flags and compare them to the 'expert's' flags unless you work through the full slide set.

The scenarios make reference to various tools and techniques for promoting patient safety. More information about these can be found in the 'Core concepts in patient safety' and the 'Tools and techniques for improving patient safety' sections. The resource will work best for you if you follow the scenarios through to completion, then access the information in the other sections to develop your learning based on the events in the scenarios. You'll also find the 'Useful resources', 'Further learning' sections very helpful in signposting you to additional materials.

Finally, the 'Taking action' section provides you with useful templates for building on the knowledge you've gained by working through the resource and using it to make a real and practical difference to the care you provide for people in your work setting.

Explore the two scenarios in the interactive animations below and see how it is a series of events that lead to the final situation. Each scenario is followed by an audio clip which analyses what 'went wrong' in each scenario, what strategies are used to investigate each case and what tools and techniques are available to improve patient safety in the future. A PDF document of the audio transcript is provided with each the audio clip.  [How to access PDF files].

Once you've explored both the scenarios, you may wish to focus your learning on the 'Core concepts in patient safety', Human factors in patient safety' and the 'Tools, techniques and taking action' sections to build your knowledge and skills to improve the care you provide and influence patient safety improvements in your workplace. The image that follows explains how to use the interactive animations.

Now you're ready to master the controls - explore the graphic below to see how to 'drive' the scenario interactions.

Scenario one

Now that you're familiar with the controls, explore the first scenario about Mrs Forrest, an elderly womanwho had been diagnosed with dementia and is living in a residential care facility. Follow her journey as she experiences admission via and Accident and Emergency department to an acute hospital ward and is discharged back to her care home. Remember, this scenario is based on real events and the investigation summary that follows has been developed by patient safety experts. When you've explored all the interactive features of the scenario, listen to the audio discussion between the ward manager and Mrs Forrest's daughter to learn about how the case was investigated and what the outcome was. As you work through the scenario, think about how easily these or similar events might occur in your work setting and visit the other sections of this learning resource to find tools and techniques you can use to ensure a patient safety focus is embedded into the care you provide.

Reminder: if you are exploring these scenarios from a computer where this learning resource has been used previously, the settings for the slides and the incidents of the last visit will remain. You may need to reset the scenario to slide one and clear the incidents before you begin (refer to the bottom of the instruction graphic to see how easily this is done).

Scenario one - summary of investigation and outcomes

Now that you've worked through Mrs Forrest's story, listen to the discussion between Mrs Forrest's daughter, Eva White and the ward manager to learn about how the incidents were investigated and what the outcomes were. You will find more detail about the patient safety concepts and the tools and techniques referred to in this audio clip by visiting the other sections in this learning resource. A transcript of the audio discussion is available on the audio clip player.

Scenario two

Scenario two is about Mr Mills, an gentleman who suffers with depression who receives support from a community psych nurse (CPN) Brian Hannah. Mr Mills' depression appears to be deepening and he consents to admission at his local psych unit to reassess his condition. Follow the story as Mr Mills develops a deep vein thrombosis requiring his transfer to an acute medical ward and the events that unfold after his discharge home. Remember, this scenario is based on real events and the investigation summary that follows has been developed by patient safety experts. When you've explored all the interactive features of the scenario, listen to the audio discussion between Brian Hannah and the acute medical ward manager to learn about how the case was investigated and what the outcome was. As you work through the scenario, think about how easily these or similar events might occur in your work setting and visit the other sections of this learning resource to find tools and techniques you can use to ensure a patient safety focus is embedded into the care you provide.

Reminder: if you are exploring these scenarios from a computer where this learning resource has been used previously, the settings for the slides and the incidents of the last visit will remain. You may need to reset the scenario to slide one and clear the incidents before you begin (refer to the bottom of the instruction graphic to see how easily this is done).

Scenario two- summary of investigation and outcomes

Now that you've worked through Mr Mills' story, listen to the discussion between CPN Brian Hannah and the acute medical ward manager to learn about how the incidents were investigated and what the outcomes were. You will find more detail about the patient safety concepts and the tools and techniques referred to in this audio clip by visiting the other sections in this learning resource. A transcript of the audio discussion is available on the audio clip player.