Introducing the national approach to learning from adverse events and tools for managing risk and adverse events.
Healthcare Improvement Scotland developed a national approach to learning from adverse events in September 2013 and refreshed the document in April 2015. It was produced following consultation and engagement with NHS boards, clinicians, patients and a number of national groups and organisations. It was also informed by the findings from a national review programme, policies, procedures and practice in place across NHS Scotland and international evidence.
The national approach aims for Scotland to have a consistent national approach to learning from adverse events through reporting and review, which supports service improvements and enhances the safety of our healthcare system for everyone. In order to fulfil this, we are working towards the goal where Scotland:
These principles are intended to be able to applied to any care setting – not just NHS acute settings.
The national approach:
Significant Event Analysis resources.
Root Cause Analysis resources from the National Patient Safety Agency.
UK Global Trigger Tool for Measuring Adverse Events from the Institute of Healthcare Improvement.