Building a national approach to learning from adverse events through reporting and review: A consultation paper

NHS Scotland is committed to improving patient safety and a national programme of work has taken place over recent years to improve risk management1, promote incident reporting and standardisation of reporting systems and embed quality improvement methodologies to directly impact on patient safety.

In February 2012, the then Cabinet Secretary for Health, Wellbeing and Cities Strategy, Nicola Sturgeon MSP, instructed Healthcare Improvement Scotland to review the clinical governance systems and processes in NHS Ayrshire & Arran, in particular those that related to the management of critical incidents, adverse events, action planning and local learning. This followed the Scottish Information Commissioner’s criticism of how NHS Ayrshire & Arran had handled Freedom of Information requests for Critical Incident Review Reports and Significant Adverse Event Review Reports.

Healthcare Improvement Scotland published a report of their review in June 20124, which provided an in-depth analysis of NHS Ayrshire & Arran’s adverse event management system and made recommendations for improvement for both NHS Ayrshire & Arran and NHSScotland. The recommendations for NHSScotland were to:

• develop a consistent and agreed approach to the identification, investigation, reporting and learning from significant adverse events, and
• maximise the opportunities for NHS boards to share and learn from significant adverse event review through appropriate measurement.

The report suggested that a clear governance framework for reporting and learning from adverse events would support preventative measures and reduce the risk of serious harm to patients. It would also enable a culture for continuous improvement and in turn support transparency and accountability. The following six key recommendations were provided to support NHS boards in reviewing current arrangements.

• There should be an active and planned approach to involvement and engagement of key stakeholders, including patients, family and carers.
• Staff should have suitable training, knowledge and understanding to be involved and contribute to the full management of adverse events, including the implementation of actions relating to learning, change and improvement.
• All members of staff should have a clear understanding of their roles and responsibilities regarding adverse events and that clear lines of accountability are defined and reflective of the organisation’s governance structure.
• Document control and related information systems should be suitably integrated and robust to provide a complete audit trail of adverse event management from the incident occurring to evidencing change and improvement. These systems should allow ongoing thematic learning from adverse events.
• Decisions relating to the management of adverse events should be risk based, informed and transparent to allow an appropriate level of scrutiny and assurance.
• The management of adverse events should be undertaken in a timely manner and thematic learning should be appropriately disseminated and acted upon throughout the organisation.

Following publication of the report, the Cabinet Secretary for Health, Wellbeing and Cities Strategy asked Healthcare Improvement Scotland to lead the development of a national approach to the identification, investigation, reporting and learning from adverse events. This will build on the work that has already been progressed and seek to provide a consistent approach for managing and learning from adverse events for the whole of NHSScotland.

Although Healthcare Improvement Scotland has been tasked to lead development of the national approach, individual NHS boards are responsible and accountable for managing their clinical governance processes. Therefore, it is essential that the national approach is developed with colleagues from across NHSScotland. This paper has been shaped by a number of discussions with colleagues from across the service and Scottish Government, and has been informed by current NHS board policies and examples of adverse event management systems from both within and outside the healthcare sector (Annex A).

In parallel to the development of a national approach to reporting and learning from adverse events, Healthcare Improvement Scotland is also carrying out a rolling programme of reviews across NHS boards to provide assurance that NHS boards are effectively managing adverse events. As part of this programme, all NHS boards submitted baseline returns which outlined how their current processes for managing adverse events met the six key recommendations and any future plans. This information and the review visits themselves will also be used to inform the national approach.