Safety Checklist - Questions everyone should ask about safety

Resource booklet for NHSScotland Board Members, with an interest in Clinical Governance.

Q4: How is learning from adverse event reviews fed into local improvement programmes, including the Scottish Patient Safety Programme? (Are our systems and processes reliable; are we responding and improving?)

Why is it important?

The response system is always more important than the reporting system. A robust methodology should be in place to ensure adverse events are thoroughly reviewed so that all contributing factors are identified and any recommendations and improvements are implemented successfully. Providing feedback will enhance reporting, learning and improving. There must be clear, rapid and useful feedback on lessons learned and actions taken.

What does 'good' look like?

  • Our staff are trained in review methodologies such as cause charts, fishbone diagrams and five whys, and understand how human factors (people, activity and environment factors) can combine to cause an adverse event.
  • Lessons learned are implemented, where relevant, throughout the organisation and not just the specific location where the adverse event occurred. Improvements are planned and carefully monitored.
  • Our Board members and staff across the organisation receive regular feedback showing results of reviews and improvements.
  • Our Board members ask what has happened with the results of previous reviews.
  • Staffing problems that have an impact on patient care are identified and rectified.
  • We thank staff for their contributions.
  • The system is focused on learning and makes extensive use of improvement methodology to test and implement the necessary changes.
  • Near misses are reviewed regularly to promote learning and system improvements.
  • The local infrastructure that supports safety should link with those managing adverse events in order that learning and improvement activity are aligned and coordinated.


Email: Sarah Hildersley

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