Safety Learning Reviews (SLRs)
Welcome to this webpage containing practical educational resources on conducting Safety Learning Reviews in Scotland’s health and care systems.
The webpage contains a selection of useful resources which we recommend that those who lead on, participate in, and sign-off SLRs become familiar with.
However, we also strongly advocate that more formal training in these approaches is a prerequisite for conducting this important review and learning activity in a meaningful and effective manner – please see details on the certificated e-learning programme below.
What are SLRs?
A Safety Learning Review (or SLR) is simply a generic term for describing any type of organisational level attempt to investigate and learn from unwanted, impactful safety incidents that have occurred, with the goal of putting in place more effective risk controls to minimise future reoccurrence. Different organisations will use different terms for this important learning process, too many to go into here, hence the decision to use a generic and neutral term with a clear educational and improvement focus and intent.
The Systems Approach to SLRs
The ‘systems approach’ to SLRs is synonymous with taking a ‘Human Factors’ approach – both ‘systems thinking’ and the ‘systems approach’ are foundational to the Human Factors discipline.
The SEIPS (or Systems Engineering Initiative for Patient Safety; Carayon et al, 2012) framework is the most well-known Human Factors based ‘systems approach’ in healthcare.
This ‘systems approach’ is illustrated in Figure 1 through its depiction of a work system that is generic and applicable to any facility in any healthcare sector (e.g., operating theatre, community pharmacy, ambulance vehicle, mental health ward, open plan offices, staff dining room).
The focus of the care work system on the left of the diagram is on characterising the interactions between people and five other system elements or components:
- job tasks
- tools and technology
- the physical environment
- person level factors
- organisational of work, and
- external influences such as safety legislation, regulation and national policy.
A fuller description of the performance influence factors related to each of these work system elements that can enhance or degrade performance, and wellbeing is also illustrated in Figure 1.
We can use this framework to better understand how and why different system elements interacted to influence unwanted outcomes, such as those that result in SLRs.
It is important to note that it is the complex interactions and inter-dependencies between these system elements that combine to create both wanted and unwanted outcomes related to overall work system performance and human wellbeing, outlined on the right side of the diagram. The framework acknowledges that work systems and processes are dynamic and constantly adapt (illustrated by the arrows as feedback loops) and, critically, that from related work system (sometimes unpredictable) interactions, both wanted and unwanted outcomes emerge.
SEIPS quick reference guide and work system explorer
NHS England - SEIPS quick reference guide and work system explorer