This report is a reflective essay on Critical Incident Analysis (CIA) written by a second year Operations Department Practitioner (sODP) student. The article analyzes a multidimensional, multifaceted critical incident using Gibbs' (1998) reflective cycle, which focuses on communication, multidisciplinary teamwork, and holistic patient care. In this report, confidentiality is maintained as specified in the Data Protection Act (1998) as well as the Health and Care Professions Council (HCPC, 2016). This literally means that the individuals' name, confidence and location are anonymized in the report and verbal consent has also been sought and approved for the release of information. Say no to plagiarism. Get a tailor-made essay on “Why Violent Video Games Should Not Be Banned”? Get an original essay According to Fook (2012), reflection is the active process of examining, analyzing and evaluating experiences, drawing on theoretical concepts or previous learning in order to inform future improvements. Simply put, thinking is a form of mental processing with a goal and expected outcome that applies to relatively complex ideas for which there is no obvious solution. The benefits of reflection among healthcare professionals cannot be overstated due to the fact that it is essential for improving skills and also useful for processing thoughts after critical incidents (Koshy, 2017). More importantly, reflection has become a fundamental part of continuing professional development and has been identified as one of the key ways in which learning can take place. by experience. Critical thinking is essential in healthcare, not only because it bridges the theory-practice gap, but also because it optimizes clinical work practices (Ghaye, 2005). The Health and Care Professions Council requires registered practitioners to use reflection in their daily practice (HCPC, 2016; NMC, 2015). The success of each reflection relies on practice and coaching in the form of a reflection cycle. There are different varieties of cycles that can be used to guide the user in continuous learning, and support, assimilation of learning, and future recommendations (Howatson-Jones, 2016) are examples of reflective cycles : Boud, Keogh and Walker (1985), Mezirow (1981), Schon's reflective theory. (1993), Kolb's experimental cycle (1984) and Gibbs' reflection cycle (1998). The Gibbs thinking cycle is one of the most cited thinking cycles, particularly in the healthcare sector (Rolfe, 2011). A reflection cycle model will be used. The reflection cycle consists of a cycle of six stages, as shown in Appendix 1. The first stage is description where the event is described in detail, followed by the evaluation of the reflector's feelings in the second stage. The third stage is the evaluation of the advantages and disadvantages of the experiment as well as the final result of the experiment, while the fourth stage focuses on the analysis of the event, the reasons why things happened unfolded as they did and personal contributions to it. . The fifth step is the conclusion which focuses on what could have been done differently, why it was not done and lessons learned, while the sixth and final step is the action plan which focuses on preparation and improvement steps and a better experience for next time. This model will be used because it encourages a clear description of the situationcurrent and also has a unique structure to follow. Additionally, the Gibbs model connects practice and theory by questioning assumptions and exploring new ideas to promote self-improvement. However, according to Johns (2017), Gibbs' cycle of thinking lacks an intellectual advantage over other approaches, but Gibbs' final stage allows for a new cycle of thinking. The SODP thinks using the Gibbs thinking cycle as it has been shown to be simple and well structured. .Critical Incident Analysis (CIA) is an approach to dealing with challenges in daily practice, particularly in medical and other sensitive areas (Lister, 2007). The CIA process involves thoroughly investigating the details of an incident, including probable causes, who was involved, when, why and how the incident occurred, and a recommendation for a practice or a future event. According to Jasper (2011), the CIA is the review of such incidents, which allows for a detailed examination, the root cause of the incident and how to make changes to future practices. It is called "critical" because it is significant, but it is an incident because it is an example of something that happens. The CIA is based on real situations which promote the active engagement of professionals in the construction of their own knowledge (Okes, 2009). CIA is often used to facilitate reflective learning in practice (Lister, 2007), although it can also expose learner vulnerabilities as well as increased anxiety levels. (Vachon, 2011). However, Lister (2007) believes that the CIA is a valuable tool, which allows practitioners to develop anti-oppressive practice. The analysis and evaluation of CIA is done using specific tools, called root cause analysis (RCA) tools (Okes, 2009). These tools allow a systematic investigation to be carried out to determine the reasons behind incidents in order to prevent others from happening again (Anderson, 2006). Additionally, RCAs are useful in detecting areas of change, improvement, and recommendations, especially in healthcare settings, ultimately leading to safe and effective patient care. There are different investigative tools for conducting RCA, such as Ishikawa fishbone diagrams, brainstorming, flowcharts, Five Whys, and affinity diagrams (Andersen, 2010). The Five Whys are one of the simplest RCA tools because the interviewer keeps asking “Why” until a meaningful conclusion is reached. Ishikawa fishbone diagrams are most useful when the “five whys” are too basic to use; it is a causal process that seeks to understand the possible cause by grouping it into subcategories (Barsalou, 2015). The author chose to use the 5 Whys technique (presented in Appendix 2) because it is simple, effective and also more appropriate for the CI discussed. Description – Appendix 1 A full description of the incident involving patient misidentification is detailed in Appendix 1. Prior to the incident, the student was in good spirits, having just entered the hospital and having put on the correct uniform. After discovering that the operation had almost been performed on the wrong patient (near miss), the student felt devastated that such an error had been made, an error that could have been potentially fatal and catastrophic if it had gone unnoticed. The student was dejected, sad and afraid and quickly thought about her practice and her future in such a profession where such an error would have led to disastrous consequences that couldlead to resignation and end of career. One of the student's good feelings was that the Health Care Assistant (HCA) supported her by admitting that she had made a mistake in printing the ID tags. There were both negative and positive aspects to the incident. The main negative aspect was a patient identification error, which could have resulted in disaster if the error had not been detected. As a risk management tool, the WHO Disconnect Section verified that the description, quantity and patient identification of all samples are correct (WHO, 2009). A negative aspect was the HCA's incorrect printing of identification labels in the patient room. It is imperative that once an ID tag is printed, it is accurately verified with the patient before using it as a patient wristband tag or a tag for patient items. On the plus side, the error was caught, therefore preventing an event ever. The HCA also recognized that printing the wrong stickers and labels and not double-checking with the patient is poor practice. However, the error was corrected when the HCA himself interviewed the patient before entering the operating room and the patient confirmed that the name and other details were wrong. This has helped avoid “never events”, which according to the Department of Health (DoH, 2012), are entirely preventable serious incidents because safety guidance or recommendations providing strong systemic protective barriers are available at the national level and should have been implemented. by all health care providers. Recognizing her limitations, the student did not complete the specimen book and therefore waited for the HCA. Although specific responsibility lies with all parties, it is worth mentioning that professional responsibility lies with the surgeon and brushing practitioner (Local Trust Policy, 2017). The Department of Health (2010) states that healthcare organizations and professions have a duty to provide quality and safe care, which should be expected by the community they serve. The introduction of the 6Cs provides the foundation of values ​​for leading change and is one of the great legacies created through “Compassion in Practice”, a three-year strategy which was concluded in March 2016. The 6Cs are the attention, compassion, competence, communication. , courage and commitment. These 6Cs are embedded throughout and constitute a set of values ​​for compassionate care that enable practitioners to work effectively, efficiently and safely (Department of Health, 2012). It ensures patient safety and practitioners adopt a holistic approach to patient care. The UK National Health Service (NHS) introduced clinical governance in the 1990s to combat overspending, which had become an ineffective management system leading to low overall public trust in the NHS. . This framework ensures that all individuals and providers can ensure the provision of good quality care that can be continuously improved (Department of Health, 2011). Clinical governance ensures patient safety and risk management (Flying Start, NHS 2016). In a similar vein, national organizations have been established, such as the National Institute for Health and Care Excellence (NICE) and the Care Quality Commission (CQC), to establish and maintain high standards of patient safety and quality (Haxby , 2010). Governance is made up of seven pillars called education and training, audit, clinical effectiveness, patient and public experience, managementrisks, information and IT and personnel management (Haxby, 2010). The local trust has adapted six themes from the seven pillars which are information focus, staff focus, patient focus, quality improvement, leadership and public health. Providing comprehensive and comprehensive patient care can be realistically achieved when all pillars/themes of clinical governance are met. The application of clinical governance with the five whys showed that the incident described in Appendix 1 was multifactorial, that is, caused by a number of factors. problems. Key factors involved in the incident which will be analyzed include poor communication, teamwork, staff concentration, wristband tags, WHO checklist, information breach, inadequate clinical effectiveness, teamwork and risk management. Poor communication is bound to cause problems. particularly in the healthcare sector. Teamwork and effective communication are requirements of the HCPC (Leonard, 2004) in order to meet the standards of clinical governance that all healthcare professionals should follow (DoH, 1997). In this incident, communication, teamwork and adherence to protocol were very good, which is why the error was discovered. According to Vermeir (2015), communication is an integral part of the seven pillars of clinical governance. Deland (2018) showed in the article that there is a strong positive relationship between a healthcare team member's communication skills and a patient's ability to follow their medical instructions, recommendations, self-manage a chronic illness and adopt preventive health behaviors. Good teamwork has also been reported in many articles to have a significant effect on improving patient outcomes and improving patient safety in a dynamic and approach that will reduce human risks. factors that can lead to patient safety incidents. According to Carayon (2013), the human factor is inevitably the cause of natural human errors that can have a significant impact on patient safety. However, this can be minimized by employing a good teamwork approach and effective communication in all patient-related matters. According to the World Health Organization (WHO, 2008), communication failures are the leading cause of many healthcare-related incidents or near-misses. In this particular case of a misidentified patient, poor communication could have made the incident worse if the HCA had not informed other team members of the error. Most importantly, the highest hierarchy among professionals in the surgical department took the position of an assertive leader and made decisions about who, how, and what to report as an incident. CQCs (Care and Quality Commissions) require the reporting of “incidents”, “near misses” and “never events” which can result in sanctions for the organization. Incident reporting, including “near misses,” is an aspect of risk management that allows health care providers to learn from their mistakes and subsequently develop strategies to improve patient safety. The purpose of reporting incidents is not to blame anyone, but to avoid the recurrence of such incidents which could be catastrophic and damaging. According to the 2016 National Patient Misidentification Report, there is clear and in-depth data on the causes and impacts of patient misidentification issues.