Bacon, A.Morris, R.Runciman, W.Currie, M.2006-12-032006-12-032005BMJ Quality and Safety, 2005; 14(3):e25/WWW 1-WWW 71475-38981475-3901http://hdl.handle.net/2440/17177© 2005 BMJ Publishing Group Ltd.Preventing harm to the patient is the priority during a crisis. After a major incident, and especially when a patient has been harmed, there are a number of matters to be addressed: the ongoing care of the patient; documentation of the incident; investigation of the root causes; completion of reports; interviews with the patient and/or the next of kin, together with apologies and expression of regret; updates and ongoing support for friends and relatives; a word of thanks to the staff involved for their assistance; formal debriefing of staff for quality assurance and possibly ongoing support and a separate debriefing for psychological purposes; ensuring that the recommendations of the root cause analysis are carried out; or, failing that, that the issues are logged on a risk register. The extent and depth of the follow up protocol depends on what, if any, harm may have been done. This may constitute completion of an incident report; notification of an equipment failure to a federal regulatory authority; arranging consultations with a mental health professional to manage psychological sequelae (especially following an awareness episode); follow up during weeks of intensive care treatment; or, when a death has occurred, a full medico-legal and/or coronial set of procedures. A précis is appended in an action card format.enAnaesthesia mishapsprotocolslegal processespatient awarenesscritical incident stress debriefingunexpected deathcrisis managementJournal article002005056110.1136/qshc.2002.0043330002295433000422-s2.0-3454809858254959