The primary aim of adverse event management in healthcare is to enhance patient safety by learning from the failings that have occurred within the healthcare system. Reporting is crucial to highlight risks and to continually improve the safe and effective delivery of care. However, system failings must be reviewed by staff with the appropriate blend of skills and knowledge.
Every adverse event report is an opportunity to learn and prevent or minimise harm occurring again in the future. Preventing, or minimising the chance of recurrence is dependent on a quality review of the situation. NHS Scotland owes patients or staff who have been directly affected by healthcare adverse events the assurance that the reviews of such cases are completed and that the learning will be used for prevention.
There are various recent press reports related to the inconsistencies in adverse event management across NHS Scotland and how this potentially can lead to the ineffective management of cases, poor quality reviews, meaningless learning outcomes and inconsistencies in communicating with patients and families. The standardisation work that the joint commission is leading is a project to harmonise coding so reports are submitted consistently, the data that is captured is meaningful for learning. Additionally, because the data capture would be consistent, the possibility of Boards learning from each other through the sharing of learning outcomes is much more realistic.