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:
- uses a common definition and categorisation of adverse events
- reports a core dataset following an adverse event
- informs and involves patients and staff in adverse event reviews
- captures consistent information in adverse events review reports and uses a common approach to redaction
- actively shares learning from adverse events through contributing quality and timely information to a national learning system
- translates learning from adverse events to make service improvements
These principles are intended to be able to applied to any care setting – not just NHS acute settings.
The national approach:
- provides a framework to support NHS boards standardise processes of managing adverse events
- focused on learning and making service improvements
- the principles are not new, but implementation at a national level is new
- for the first time in Scotland a common definition
- framework that is applicable to clinical and non-clinical events, across specialties and services
- contributes to the delivery of our 2020 vision (services are safe) and strategic aim of reducing avoidable harm
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.