Could This Happen

Could This Happen in Your Program 

    Is a series of stories based on Commission investigations.  The objective of the series is to prevent accidents and other problems in programs by learning from the experience of others. We hope that you will use these stories as a training resource for direct care staff and to spark reflection and discussion about your program’s policies and practices to reduce the likelihood of similar incidents.

Please copy and distribute the complete cases for teaching or learning purposes. All the names have been changed and pseudonyms have been used in each of these cases.

		In the Matter of Ned Moffat: The importance of family involvement and follow-up in suicide prevention
		In the Matter of Chris North: The Importance of Differential Diagnosis in Psychiatric Settings.
		In the Matter of Erin Federov: Choking Prevention and Quick Response Saves Lives.
		In the Matter of Jamal Grey: Preventing elopement from a community residence.
		In the Matter of Alex Jacobs: Preventing elopement during community outings.
		In the Matter of Donna Osborne: Providing Life-Saving Treatment Over Objection
		In the matter of John O'Clair: Keep investigating incidents until all the questions are answered.
		In the matter of John Dove and Jimmy Carol: Monitoring the effects of psychotropic medications.
		In the Matter of Neil Larkin: A Case Study on Restraint, Traumatic Asphyxia and Investigations.
		The Hazards of Diabetes Management.
		In the Matter of James Manning: A Case of Unrealistic Supervision Expectations.

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Could this happen in your program archive