REPORT FORM
TITLE OF REPORT:
NAME:
ADDRESS/LOCATION:
Antipsychotic Treatment for Asperger’s
Practice Nurse
GP Practice
EMAIL:
DATE EVENT IDENTIFIED:
DATE REPORT
COMPLETED:
WHO CONTRIBUTED TO THE ANALYSIS?:
Practice Manager, Receptionist, GP, Practice Nurse (Senior), Practice Nurse
 Evidence suggests that the application of ‘Human Factors’ knowledge enhances
performance and wellbeing in the workplace and improves understanding of the complex
system interactions which contribute to significant events.
 A simple way to view the discipline of ‘Human Factors’ is to think about the interactions
between three work-related factors: People, Activity and the Environment – and how
they can combine to impact on people’s health, safety-related behaviour and patient care.
 This report can be completed after analysing the significant event on your own, or it can
reflect the comprehensive analysis carried out by your wider care team.
 The key to a more in-depth analysis is identifying the system issues and interactions that
contributed to a significant event.
 A deeper understanding of why the event happened will prompt a more focused,
meaningful and detailed Action Plan for improvement.
For more information visit the enhancedSEA website: www.nes.scot.nhs.uk/shine/
1. About the Significant Event
Please describe what happened
(Please outline in sufficient chronological detail including how it happened, who it happened to and the
location of the event).
A paranoid schizophrenic patient with Aspergers Syndrome and attention deficit hyperactivity disorder
attended the surgery with his mother who acts as his guardian. The patient came a day late for his
appointment for the administration of an intramuscular injection. The patient stated that he was convinced an
error had been made on the part of the surgery regarding the date of the appointment. The receptionist called
the practice Manager to speak to the patient and his mother as there were no available appointments left for
that day. The patient and his mother were not happy with the situation and demanded that they see a
practitioner for the administration of the injection. The Practice manager spoke to a GP and the senior Practice
nurse neither of whom could see the patient. The Practice Manager then came and spoke to a more junior
practice nurse undertaking non clinical duties. The Practice Manager explained the situation about the
appointment time and asked if the nurse would administer a depot injection The nurse agreed to give the
injection thinking it was for a depot contraceptive injection. On returning the Practice Manager gave the
medication to the nurse adding the patient had just popped out for some air as the waiting area was busy. The
nurse noticed the medication was for a male patient and was an unfamiliar antipsychotic prefilled medication.
She read through the leaflet to familiarize herself about the medication and route of administration, ensuring
she was competent and comfortable to administer the medication. When bringing up the patient’s record on
the computer screen she noted his psychiatric disorders and that he had a problematic behaviour with a
history of violence and normally saw male doctors.
At this point the patient entered the consultation room without being called asking for his injection. The
patient’s identity and medication were checked against the prescription; it was then administered as
prescribed and requested. The patient displayed unsettling, unnerving mannerisms and appeared to have a
very random and non-coherent thought process and did not appear to want to leave the consultation room, but
instead wanted to stay and chat. After approximately five minutes the nurse managed to bring the consultation
to a close and the patient left the room but she was feeling very vulnerable. She took her concerns about the
incident to the Practice Manager.
What was the impact or potential impact of the event?
(Please consider what may have been the emotional effect of the event on yourself and others, where
appropriate, and the clinical, professional and organisational implications).
The Practice Nurse was put at potential risk. She was made to feel very uncomfortable and also aggrieved at
being asked to do a task she did not initially feel competent to do. The apparent lack of support from her
Senior nurse and the GP in the practice may impact future relationships in the team. The patient may have
suffered had the Practice nurse not completed the task competently.
The incident generated a potential lack of confidence in the appointment system for any other patients
observing the incident
2. Applying a Human Factors Approach
Please outline the different system factors that contributed to WHY the event occurred, taking into
account how these different factors interacted with each other and led to the event happening.
(People Factors (e.g. severity or uncertainly associated with patient condition; social and personality factors; clinician and staff training,
skills, knowledge & competence; and physical and psychological characteristics such as fatigue, stress, motivation and needs).
Activity Factors (e.g. job task demands such as mental and physical workload, decision-making, time pressure, attention levels,
distractions and interruptions, volume and complexity of tasks; and interacting medical device, tools and technology issues such as their
availability and usability).
Environment Factors (e.g. organisational issues such as how work is done, teamwork, verbal & written communication; staff levels, skill
mix & shift patterns; information flow; leadership, management and supervisory issues; physical environment factors such as lighting,
noise levels, workspace layout and design; prevailing safety culture & priorities; polices & standards; financial resources; and external
pressures).
Think in-depth about the interactions between people, the activity you were undertaking and the immediate
and wider healthcare systems and environment that you work in)
The factors that contributed to this situation were that the patient was ill and appeared to be confused with the
date of his appointment. He had become unsettled and agitated; he was seeing a practitioner he had never
met before. The nurse felt under pressure and a bit aggrieved when she learned the nature of the task
normally done by someone more senior. The nurse was unprepared regarding the patient and their medical
history and unfamiliar with the medication. She felt unsafe as the patient was clearly displaying unusual
behaviour.
This event was potentially a safety risk, clinically, professionally and organizationally The positioning of the
furniture in the consultation room meant that if anything had occurred there was no clear exit to leave the
room. There was no emergency alarm system in place to attract attention or get help quickly.
Other environmental factors included the workload pressure at the surgery as the existing clinics were full, the
waiting area was full of patients waiting to be seen.
The other factors that combined to make this event happen and to contribute to the discomfort of the Practice
nurse were lack of communication between the Practice Manager and the nurse as she wrongly assumed it
was the usual type of contraceptive depot injection she was familiar with administering. The task was viewed
as an easy, quick procedure that did not require any special environmental considerations that could be
carried out in any private room within the surgery.
3. Lessons Learned
What lessons have been learned from the analysis of this event (as appropriate):
 At the individual level?
 At a care team level?
 At an organisational level?
 At the interface of primary and secondary health care?
 At the interface between health and social care?
The lessons that have been learnt are the need to better communicate information between staff, between
staff and patients and that judgment regarding the administering of medication is a decision to be made by
clinical staff. The physical layout of consulting rooms and no access to an emergency alarm system was
recognised as a risk. The nurse had not attended recent violence and aggression training
The nurse felt able to communicate her concerns to the practice manager and an eSEA was conducted by the
practice team. The team recognised that the nurse felt she was placed in a vulnerable position and that action
should be taken to reassure her and put in place action to avoid another situation like this .
4. Action Plan for Improvement
What action has been taken to-date to minimise the chances of this event happening again?
As a result of discussion among the team the clinical consulting room layouts have been
altered so that there are clear escape routes. The practice installed new telephones
which have an intercom facility to allow the operator to alert all staff of an emergency
situation or the need for assistance. The practice have implemented a new system for
calling vulnerable patients to remind them of their appointments, along with trying to
book patients into appropriately timed clinics so waiting rooms are not too busy, and
ensuring the person sees the most appropriate staff member.
What further action do you plan?
(Outline your Action Plan for Improvement and how and when you will implement it together with the role and
contribution of the wider care team where appropriate. Also consider how you might share any interface issues
or external factors that have contributed to this event but which you deem to be out with your control. Think
again about taking a systems approach to improvement and consider the complex interactions between
People, Activity and Environment already identified.
The practice staff are expected to attend yearly updates of prevention management of violence and
aggression training to recognise potential threats of violence and aggression.
Who is responsible for ensuring that these actions are implemented and how will these be
monitored and sustained in practice?
(Outline your role and contributions and those of the wider care time where appropriate).
The Practice Manager had responsibility to co-ordinate implementation of the safety adaptations to the
consulting and treatment rooms and for the upgrade to the telephone system and the Office Manager is tasked
with monitoring this. The Practice Nurse and receptionist devised the call system for vulnerable patients with
input from the GPs and this was written as a practice policy and disseminated to all the admin team. This will
be reviewed in 12 months.
If you did not have the opportunity to analyse this event with colleagues, what were the barriers?
(Please complete where applicable).
n/a