Candour Clock
Find the harms nobody reported, tell the family, prove every ward learned.
The job
Finds harms that patients and families described but incident reporting missed. Turns each into a clinical review, an honest disclosure to the family within a set deadline and proof that practice changed, then spreads the lesson to every unit with the same risk.
The moment
The board quality committee follows harms found in what patients and families said, each tracked through five rings that close one by one. Today the last ring closes on a fall on ward 4B at 02:10.
The review found moderate harm. The family was told in person on day 3 and by letter on day 5, and a bed-rail check was added to every night shift.
There have been no falls on 4B in the 60 days since. The patient's daughter replies on WhatsApp: "Thank you for being honest with us."
A map then shows eleven similar wards that adopted the same check. Falls across the network in 30 days are down from 23 to 9.
What it does
- Open and grade a candour case
- Log to the incident system
- Draft and send the disclosure letter
- Book the candour meeting
- Family follow-up
- Send a learning card to sister units
What you see
Case file with five candour rings closing one by one, an unreported-harm league, and a sister-unit ripple map for the board committee
What it moves
Harms patients describe that staff didn't report, by unit, the median days until the family is told, the share of cases disclosed in writing within the policy deadline, and whether the same harm recurs 60 days after the change.
Built for
- QA, training & knowledge
