you will likely have been involved (directly or indirectly) with a patient who was the victim of an adverse event or near miss or will have been made aware of such a case. Choose one such case from your clinical experience and identify the type of risk present (for example – medication error, diagnostic error, handover error, inappropriate discharge from care). You are to research this presenting risk as it relates to your case and address the below points in the form of a case study. Credible literature must be used to back up statements and to form discussions, analysis, and debates. 1. Include an introduction. 2. Provide a background (brief overview) of the case and the presenting risk. Fill out a Swiss Cheese Model diagram relating to the case. 3. Analyse the human factors that contributed to this risk occurring in your case and the impact of these on health care. 4. Describe structured approaches to risk management in the context of your case. 5. Discuss ethical and legal parameters as they relate to your case. 6. Analyse and debate the merits and shortfalls of risk reduction strategies, programmes, methods and/or initiatives in relation to your case.
