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Filename: AE C&C consultation Produced by: CS/AW

A NATIONAL APPROACH TO LEARNING FROM ADVERSE EVENTS

Consultation:

• Capability and Capacity

• Expert Reviewer Network

• Never Events

To inform the Learning and Improvement Working Group’s key deliverables, we consulted with NHS boards(February 2014) on a range of capability and capacity factors in their management of adverse events, including:

• Training

• Review timescales

• Review team configuration and leadership

• Challenges in developing capability and capacity for significant adverse events

• Links between learning from adverse events and local improvement programmes

• Mechanisms for learning from other NHS boards significant adverse events

• The premise of an expert reviewer network (remit, resourcing, benefits/drawbacks/risks)

• Current use and benefits of reporting Never Events The attached consultation document includes the NHS board’s responses and a summary analysis. An action group will review the analysis to inform how we can share NHS board’s approaches to training and consider mechanisms for facilitating training. It will methodologies/tools used and how we can facilitate sharing learning from adverse event reviews to drive improvement. The Programme Board is asked to consider the feedback received, and in particular advis

proposed actions:

• Provide a repository of NHS board’s adverse event training packages on the Adverse Events Community of Practice website.

• Provide a repository of NHS board’s adverse event reviews tools/methodologiesAdverse Events Community of Practice website.

• Facilitate ‘train the trainer’ events on key topics (first proposed topic Value Based Reflective Practice).

• Establish a national network to share learning and deliver improvement initiatives (eg safety cases).

• Design a template for sharing learning from adverse events (both on the review process and on review outcomes/service improvements) on the Adverse Events Community of Practice website.

• In addition to the above, further develop the Adverse Events Community oinclude: an area for each NHS board to share good practice examples; information from national stakeholders (eg Procurator Fiscal, SPSO); a national notice board for events/seminars; discussion forums; a space for network papers and w

AEPB/14/18

Version: v0.1 Date: 3 Sept 2014 of 50

Status: For Consideration by PB

A NATIONAL APPROACH TO LEARNING FROM ADVERSE EVENTS

Capability and Capacity

Expert Reviewer Network

To inform the Learning and Improvement Working Group’s key deliverables, we consulted with NHS boardson a range of capability and capacity factors in their management of adverse events,

Review team configuration and leadership

Challenges in developing capability and capacity for significant adverse events

ween learning from adverse events and local improvement programmes

Mechanisms for learning from other NHS boards significant adverse events

The premise of an expert reviewer network (remit, resourcing, benefits/drawbacks/risks)

reporting Never Events

The attached consultation document includes the NHS board’s responses and a summary analysis. An action group will review the analysis to inform how we can share NHS board’s approaches to training and consider mechanisms for facilitating training. It will also consider ways of sharing the range of review methodologies/tools used and how we can facilitate sharing learning from adverse event reviews to drive

The Programme Board is asked to consider the feedback received, and in particular advis

Provide a repository of NHS board’s adverse event training packages on the Adverse Events Community of Practice website.

Provide a repository of NHS board’s adverse event reviews tools/methodologieserse Events Community of Practice website.

Facilitate ‘train the trainer’ events on key topics (first proposed topic Value Based Reflective

Establish a national network to share learning and deliver improvement initiatives (eg safety cases).

sign a template for sharing learning from adverse events (both on the review process and on review outcomes/service improvements) on the Adverse Events Community of Practice website.

In addition to the above, further develop the Adverse Events Community oinclude: an area for each NHS board to share good practice examples; information from national stakeholders (eg Procurator Fiscal, SPSO); a national notice board for events/seminars; discussion forums; a space for network papers and wikis; outputs from the action groups, etc.

AEPB/14/18

For Consideration by PB

To inform the Learning and Improvement Working Group’s key deliverables, we consulted with NHS boards on a range of capability and capacity factors in their management of adverse events,

Challenges in developing capability and capacity for significant adverse events

ween learning from adverse events and local improvement programmes

Mechanisms for learning from other NHS boards significant adverse events

The premise of an expert reviewer network (remit, resourcing, benefits/drawbacks/risks)

The attached consultation document includes the NHS board’s responses and a summary analysis. An action group will review the analysis to inform how we can share NHS board’s approaches to training and

also consider ways of sharing the range of review methodologies/tools used and how we can facilitate sharing learning from adverse event reviews to drive

The Programme Board is asked to consider the feedback received, and in particular advise on the following

Provide a repository of NHS board’s adverse event training packages on the Adverse Events

Provide a repository of NHS board’s adverse event reviews tools/methodologies/templates on the

Facilitate ‘train the trainer’ events on key topics (first proposed topic Value Based Reflective

Establish a national network to share learning and deliver improvement initiatives (eg safety cases).

sign a template for sharing learning from adverse events (both on the review process and on review outcomes/service improvements) on the Adverse Events Community of Practice website.

In addition to the above, further develop the Adverse Events Community of Practice website to include: an area for each NHS board to share good practice examples; information from national stakeholders (eg Procurator Fiscal, SPSO); a national notice board for events/seminars; discussion

ikis; outputs from the action groups, etc.

Filename: AE C&C consultation Version: v1.0 Date: 3 Sept 2014 Produced by: CS/AW of 50


Adverse Events Capability and Capacity Consultation

NHS boards’ responses and summary analysis

1. How many staff, both clinical and non-clinical, have received training on how to

conduct an adverse event review. Do you have a list/register of staff who attended

and when, including their job title and management status?

NHS A&A 31 staff has undertaken the 1 day course.

142 staff has undertaken the 2 day course.

NHS A&A maintain a list of the details which includes job title and management status.

NHS Borders 48 staff attended our SAER reviewers training and 32 attended specific training for

sponsors/chairs of SAERs. NHS Borders have a list of staff who attended, when and

their job title.

NHS D&G 17 staff trained in April 2012.

16 were trained in April 2010.

NHS Fife Historically, since 2002, many staff have been trained in RCA across NHS Fife.

Since NHS Fife’s ‘new’ Adverse Events Policy was implemented in June 2013: 64 staff

have received training on conducting an adverse event review*.

Additional >36 in pipeline up to mid June 2014. This will increase, dates just issued.

NHS Fife have a list of staff with date of attendance, job title / management status*

NHS Forth Valley Safeguard training is available for all staff on reporting the event (list of attendees held

by Risk Management). Adverse Event Policy gives instruction as to what level of

investigation is required. The health and safety team deliver an Incident Management

training course.

Incident Management Training - 7 training since August 2011

IOSH Managing Safely incorporating Incident Investigation module - 43 trained since

November 2010

There is a register of attendees, their job title, ward/department, Unit and

Hospital/Health Centre

Currently planning RCA training for Significant Adverse Events.

NHS GG&C Year Acute Partnerships Total

2011 51 66 117

2012 117 45 162

2013 213 39 252

2014 (so far) 33 0 33

NHS GG&C keep lists of who the attendees are. Mixture of clinical (Medical, nursing,

AHB & laboratory staff) and non-clinical (HR) staff. More training planned for 2014 –

numbers included above is only training that has happened at the time of reporting

this questionnaire.

NHS Grampian NHS Grampian have an electronic database AT Learning and on this and have a list of

all staff who have attended the in house Incident Investigation Course and Root Cause

Analysis. They do not have an up to date list of staff who have attended training

courses that are not provided by the Board. There is a link on the AT Learning system

which indicates if /when staff have left the organisation. They have started to deliver

training to groups of staff from the same service/ sector to increase the pool and

reduce the impact on individuals’ capacity.



NHS Highland NHS Highland do not have comprehensive records.

Over the last few years the Board has provided training and resources for staff involved

in significant event reviews. These include:

- Resource pack for managers on incident management investigation

- Incident Management was covered in the Leading Better Care training for all

senior charge nurses

- Incident Management is covered on the ILM training programmes across the

Board for staff in supervisory/management positions

- Standing Operational Procedures have been developed by Raigmore Hospital

and North and West

- Operational Unit on undertaking SERs

- Detailed procedures in our incident management policy and procedures

- Ongoing training being delivered on Datix across organisation and including

adult social care.

NHS Lothian A total of 1,100 both clinical and non-clinical staff have received training on how to

conduct an adverse event review. There is a current register of all staff who attended,

and when, including their job title management status.

NHS Tayside The format of training within NHS Tayside has evolved significantly over the last 10

years from workshop led sessions to online courses. However, since April 2013, the

approach to training has been overhauled and we now run a series of courses

including:

• Roadshows – April 2013 – February 2014 = 340 participants

• DVD of Roadshows – available to all staff on Staffnet = unable to quantify

numbers

• Awareness Sessions for Verifiers – August 2013 – February 2014 = 76

participants

They have also commissioned external Root Cause Analysis training, with additional 59

participants.

They are currently in the process of reviewing and reinstating an internal Root Cause

Analysis for incident Review training.

NHS Western

Isles

29 staff attended a 1 days RCA training event.

24 staff have attended Risk Management training session’s specific to investigating an

adverse event.

NHS Western Isles has a register of staff which includes their job titles and

management status.

NHS24 Approx 6 staff – NHS 24 have a list

NWTC Total numbers not available for all staff as register not available.

The HCG and Senior Governance Lead are both trained to conduct Incident reviews

and will facilitate all such reviews. Given the size of the Board this meets need

currently although it is intended to increase the size for this pool in 2014-15.

SAS Roughly 50, some have moved on, we have a register of everyone who has been

trained.

State Hospital 32 trained staff. The information listed in the question above is recorded.

Analysis

14/15 NHS boards (not NHS Highland) have records of who has been trained in incident

management.

4/15 mention ongoing and future plans to provide training (doesn’t necessarily mean



the others haven’t got these in place).

2.

What did the training consist of, what content was covered and how was this

provided? Are refresher training courses available?

NHS A&A Training consisted of examples of system analysis tools, group work to test the tools

and a real life event to be reviewed and discussed. This was provided by an external

provider over 2 days.

No refresher courses have been undertaken.

NHS Borders The training programme is attached. We plan to run a follow learning set for those

who attended in autumn 2014.

SAE Reviewers Training Programme.doc

NHS D&G The training was Root Cause Analysis delivered by an external training organisation.

Refresher training was delivered to 16 staff members in April 2012.

Human Factors training has also been delivered.

NHS Fife Half day, face to face course using Powerpoint, DVD, Group work. In summary:

• Theory underpinning adverse event review, systems approach, just culture

• National context of adverse events, local adverse events policy & procedure,

roles & responsibilities including specific requirement around Significant

Adverse Event Review (SAER)

• NPSA approach to RCA – 6 steps

• Safety, human factors, error types, Reason’s Swiss Cheese Model

• Opportunity to review an adverse event using RCA tools and techniques e.g.

change analysis, reactive barrier analysis, NPSA Contributory Factors

Framework, 5 whys, fishbone

• DoH Case study ‘Just an ordinary day’

Course available as a refresher for staff who attended RCA training in past.

Customised programme available for specific teams.

NHS Forth Valley It covers such topics as the causes of adverse events, terminology used, legislative

requirements, root cause analysis and the methodical approach to investigation,

gathering and analysing information, identifying risk control measures including action

planning and its implementation.

Yes - refresher course available but not well attended

NHS GG&C Half a day run by a Clinical Risk Manager/ Coordinator:

Significant Clinical Incident policy and procedures toolkit.

• Statement writing and interviewing.

• Description of the Accident Causation Model (James Reason)

• Explanation of types of errors with examples (Slip/lapse, mistake, violation)

• Worked examples using the Accident Causation Model.

• DVD showing an incident and explaining how it happened.

• Explanation of Human Factors (contributory factors) with some exercises to

emphasise.

• Discussion on blame and culpability



• Any questions.

• Offer of field work

NPSA link shared on our staffnet page to be used as consolidation or a refresher.

NHS Grampian A one day Incident Investigation Course discusses the benefits of a systems centred

approach to investigations using group work and a role play mock incident

investigation. The course is open to all employees and is facilitated by a Health and

Safety Facilitator and a Risk Advisor. Attendees are encouraged to identify the system

failures and to understand the importance and relevance of incident investigations.

The benefits of a just culture are explored. Active error and latent conditions are

touched on as is multiple causation. This training introduces the concepts of RCA and

participants get the opportunity to use some of the tools. They practice developing

solutions and action plans and discuss how they share lessons locally and how lessons

are shared across the Board, via Governance Groups Staff etc

The one day RCA course supplements the Investigation course, it’s attended by clinical

leads, unit and service managers, laboratory managers and senior nurses. It was

developed and is delivered by the same staff as the Investigation Course and it is a

prerequisite that the investigation course is completed before attendance at the RCA

course.

NHS Highland The training for ILM includes RCA using 5 Why’s and Fishbone. Use the NPSA

contributory factors for RCA.

NHS Lothian The training consisted of lecture style presentation followed by practical workshop

sessions, topics covered were:-

•••• Identification and decision review,

•••• Selecting people for the review,

•••• Organisation and date gathering,

•••• Determining the adverse event chronology,

•••• Identifying care/service delivery problems,

•••• Identification of contributory factors,

•••• Making recommendations and developing an improvement plan.

The training is facilitated by experienced in-house trainers; the current full day training

has evolved from previous training courses that included refresher course training. (

See attached agenda and contents page of training material)

Tailored team based training workshops focussing on human factors are currently

developed and have been tested with maternity staff and will run for mental health

staff at the end of April 2014.

NHS Tayside Adverse Event Roadshows and DVD on Staffnet

The purpose of the roadshows are to ensure all staff are aware of: how to identify

adverse events and near misses, how and where to report adverse events and near

misses, the processes of undertaking Local Incident Reviews (LIRs) and Significant

Clinical Event Analysis (SCEAs), the importance of clinical risk management to patient

care and safety, the importance of closing the loop on actions and service

improvements following LIR and SCEAs

Adverse Event Awareness Sessions for Verifiers

The aim of this training is to ensure that participants are adverse event aware and use



information available to them to improve patient safety experience. This training

covers: national and local drivers, definitions of adverse event, harm and near miss,

roles and responsibilities of the verifier, minimum data set, grading incidents and

support available for staff, patients and carers.

Root Cause Analysis

We are currently in the process of reviewing and reinstating “A training event in Root

Cause Analysis for Incident Review”. Any member of staff who will be expected to co-

ordinate, lead or facilitate an incident review will be in position to attend. In addition,

staff already undertaking incident review will be able to access this training when they

feel they require refresher training/update. This training will cover: systems approach,

minimum data set, contributory factors, tools, techniques, procedures, meetings, local

review report, confidentiality and document control.

All above courses are held in classroom style environments. All staff are able to access

this training when they feel they require refresher training/update.

NHS WI Attach copy of report of our 1 days training event on Root Cause Analysis. Refresher

courses will be provided by Risk Manager as part of our ongoing Risk Management

Training Programme.

Microsoft Office Word 97 - 2003 Document

NHS24 It was about 6 to 8 years ago, so not 100% sure of content.

NWTC Training was externally provided and was a day long looking at all aspects of SAE

review.

SAS 2 day root cause analysis course conducted by Maria Dineen from consequence UK.

We are ensuring that people use the skills regularly and are shadowed by more

experienced reviewers to prevent skills atrophy.

State Hospital Pre 2005 we did Advanced Investigation Skills training.

Post 2005 we have linked into RCA training, this is a one day course by Consequence

UK. This was initially provided by QIS, but is now available from the Forensic Network.

We do not currently offer refresher training.

Analysis Topics Methods

• 5 why’s

• Accident Causation Model

• Description of error types

• Fishbone

• Human factors

• Identifying incidents

• NPSA Contributory Factors Framework

• RCA (Maria Dineen mentioned)

• Reason’s Swiss Cheese Model

• Recommendations, action planning and

implementation

• Risk control measures

• Roles and responsibilities

• 2 day external course

• Awareness sessions

• DVD

• Group work

• Half day internal

course

• Often tailored to a

particular team

• Power Point

• Road show



• Statement writing and interviewing

• Systems analysis tools (theory and in practice)

• Theory behind incident management process

4/15 NHS boards do not state that they offer refresher training.

3. If you provide different levels of training, what do these different levels consist of?

NHS A&A The one day course was to provide overall understanding of the process and principles

of RCA. The two day course provided in detail the tools to undertake RCA. We also

offered a Report Writing Workshop to senior personnel.

NHS Borders We provide training for reviewers and review sponsors. The training for review

sponsors is a truncated version of the reviewers training as per the attached agenda

above.

NHS D&G Manager/Reviewer training is delivered at Team Leader/ Lead Reviewer level.

NHS Fife Currently training is designed to support staff who may lead or facilitate an adverse

event review – both local review and SAER.

Intention to develop Learn pro modules to complement face to face training.

NHS Forth Valley N/A

NHS GG&C There are not different levels of training officially but the CRMs do incorporate some

aspects of the half-day session at other training opportunities – symposiums, study

days, grand rounds, meetings etc. The Clinical Risk staff also coach new investigators

through the process and QA the investigation reports.

NHS Grampian As above the initial Investigation skills course prepares most staff to conduct a review

of low-medium severity incidents, a local investigation. The RCA course is aimed at a

more senior level.

NHS Highland We deliver ILM level 2, 3 and 5. The higher the level the more in-depth we go with

focus on sharing leaning and improvement.

NHS Lothian The focus is on reviewing adverse events resulting in major harm and death; however

the principles apply to all adverse events.

Reviews of other levels of severity (No known effect at this time, minor, moderate) are

recorded as part of Datix Form and the layout has been designed to make it self

explanatory. One to One/ small group training is available for managers on request and

includes the completion of a review.

NHS Tayside Roadshows are held across NHS Tayside to ensure ALL staff regardless of level and role

have the skills and knowledge to recognise adverse event and near misses, where, how

and why to report these and the process for receiving feedback or shared learning.

Adverse Event Awareness Sessions for Verifiers – aims to ensure verifiers are adverse

event aware, understand their roles and responsibilities as a verifier, appreciate the

value of reporting and reviewing adverse events and near misses, understand the value

of appropriate grading and review criteria, are aware of policies and associated

documentation relating to Adverse Event Management and understand the

importance of improving patient safety and experience through sharing the learning.



We are currently in the process of reviewing and reinstating “A training event in Root

Cause Analysis for Incident Review”. Any member of staff who will be expected to co-

ordinate, lead or facilitate an incident review will be in the position to attend. In

addition, staff already undertaking incident review will be able to access this training

when they feel they require refresher training/update.

Finally, individual Directorates have commissioned external providers to run additional

RCA training courses tailored to specific staff groups’ e.g. mental health.

NHS WI Risk Management Training which includes how to conduct adverse event reviews.

Datix Training on completing DIF1 and DIF2 forms. Role of handler and investigator

explained.

NHS24 No.

NWTC Yes – basis AE principles are discussed at induction.

There are annual workshops for senior clinical staff across the both divisions which

look at process and principles. The aim of these is to both learn and improve process.

There are periodic workshops held for charge nurses again on principles of IR

investigation.

SAS We only provide Datix reviewer training and Root Cause Analysis training at this stage.

The plan is to develop a bespoke training package for our significant adverse event

policy.

State Hospital N/A

Analysis • General incident management/awareness sessions – all staff

• RCA – those who may lead or facilitate an SAER, generally more senior level

• Report writing workshop – senior personnel

• Reviewer training – team lead level/those who will be responsible for reviewing the

Datix report

Generally, the more in-depth/incident review training for higher levels of staff and

general incident management training for all staff during induction.

4. Who provides it?

NHS A&A Consequence UK

NHS Borders Maria Dineen was commissioned to deliver the initial set of training. The Clinical

Governance and Quality and Risk, Health and Safety teams will be involved in delivery

of future training and refresher sessions.

NHS D&G Root Cause Analysis – external provider

Human Factors – Director of Medical Education & team

Manager/reviewer – Risk Coordinator/ Risk Facilitator

NHS Fife Risk Management Team.

NHS Forth Valley Incident Management training is provided by the Health and Safety Team

SAE training is being planned although several staff have done RCA training previously

NHS GG&C Acute – Clinical Risk Managers. There are 3 in GG&C.

Partnerships/Mental Health – Clinical Risk Coordinators. There are 2 in GG&C.

NHS Grampian Both courses are provided in combination with Health and Safety facilitators and Risk



Advisors.

NHS Highland Clinical Governance Support Team.

NHS Lothian The training is provided by experienced in-house trainers. Team training events are

delivered by Clinical Governance & Risk Manager, Public Health Consultant, and

Associate Medical Director for Patient Safety.

NHS Tayside In house training is provided by the Clinical Governance and Risk Management Team.

External courses commissioned by directorates have been provided by an external

training provider.

NHS WI External Risk Management Consultant provided RCA training and Risk Manager

provides all Risk Management Training.

NHS24 N/A

NWTC Clinical Gov Staff.

SAS As above, Risk Manager and Datix administrator for Datix training and at this stage

Maria Dineen for RCA. Risk Manager and soon to be appointed clinical risk manager

will develop bespoke package for SAER framework.

State Hospital N/A

Analysis

• AMD for patient Safety

• Clinical governance team

• Consequence UK (Maria Dineen)

• Health and Safety team

• Medical education team

• RCA – often external

• Risk management team

5. How many adverse event reviews did you do in 2012?

NHS A&A Only one review was commissioned in 2012, although reviews called in 2011 were

carried forward for completion in 2012

NHS Borders 47 reviews were carried out in 2012.

NHS D&G 22 Adverse Events were considered as part of our Significant Adverse Event procedure.

A number who were also aligned to Maternity reviews and Mental Health suicide

reviews.

NHS Fife 35.

NHS Forth Valley There were 8438 adverse events logged on Safeguard in 2012. Every adverse event

technically has to be reviewed. The level of that review will be dependent on the detail

and outcome of the event. The Adverse Event Policy describes the level of

investigation required.

NHS GG&C By adverse event reviews we assume you mean significant clinical incidents that meet

our policy criteria. There were 17,306 Clinical incidents reported in GG&C in 2012 and

of them 126 were classed as significant and had a review in line with policy. There is an

option for other events to be supported through a local investigation. In 9374 were

recorded in Datix as being supported through local investigations.

NHS Grampian Our previous guidance asked that staff indicate on Datix whether a local or full

investigation will be undertaken; in 2012 there were 87 incidents that had a local

investigation and 43 that had a full investigation. It was not a requirement to upload to



review report however for the high and very high incidents it was a requirement that

the lessons learned and actions taken as a result of the incident and review should be

uploaded, 88.4% of the incidents with that severity had either or both lessons learned

/ actions taken uploaded on the system.

There will definitely have been many more reviews carried out on Medium/Low

incidents and even more relating to trends, however these would have been

conducted locally and the reports would probably not have been uploaded to Datix.

NHS Highland In 2012 there was a total of 11763 incidents.

Consequence Total reported Total with information in

investigation

Negligible 6212 1822

Minor 3818 1829

Moderate 1055 580

Major 51 25

Extreme 29 25

Total 4281

24 of these adverse events were noted as SER / suicide.

400 of the 11763 incidents were adult social care so there is no investigation details/

graded provided as these were on the council forms.

NHS Lothian All adverse events are subject to review, which totalled 28,067 in 2012. Those resulting

in major harm or death (312 in 2012) are subject to comprehensive review

documented on the standard template (see Q3).

The remainder were reviewed and documented in Datix.

• No known adverse effect at this time = 20,918

• Harm to a person – minor = 5,318

• Harm to a person – moderate = 813

• Damage or loss to property – No known adverse effect – 706

NHS Tayside In 2012 we moved from the AIM system to Datix for reporting all incidents:

April 2012 – September 2012 there was a total of 52 red incidents reported on the AIM

system with all incidents having an incident review.

September 2012 – December 2012 there was a total of 99 red incidents having

information recorded under local incident review section.

27 Significant Clinical event analyses were carried out in 2012.

NHS WI In 2012 we conducted 10 Root Cause Analysis reviews on adverse events.

NHS24 About 30

NWTC 12 Incident reviews.

SAS N/A

State Hospital For calendar year 2012 we conducted 16 reviews.

Analysis • 12/15 provided in relation to SAEs

- Range: 1 - 312

- Average: 55

• 6/15 provided in relation to AEs



- Range: 87 – 28,067

- Average: 8,400

6. How long does it take from reporting an adverse event to completing a review? Do

you have data to support that number?

NHS A&A Guidelines for Management of SAER states that review should be completed 75 days.

The organisation has found that this timeline is difficult to achieve, partly due to team

clinical commitments. This is being reviewed by the organisation.

The last six days significant adverse event reviews have been completed in an average

of 136 days (range 75 – 306 days). We have data to support this calculation.

NHS Borders If you are referring to significant adverse events in this questions we have a 6 week

timescale which is integral to the SAER process, this is taking sometime to embed and

in reality some reviews are taking longer than 6 weeks to bring to full conclusion. We

hold a tracking database to monitor this for significant adverse event reviews.

NHS D&G NHS D&G have 3 months to open, investigate and close Significant Adverse Events.

Datix can supply open/closed data.

NHS Fife Local review- average 57 days

One recently completed SAER- 134 days. Seven live SAER underway not yet concluded.

Yes, we have data to support the numbers since implementation of the ‘the new’

Adverse Events Policy.

NHS Forth Valley The seriousness of the event will identify what the timescales would be as per policy.

Variable times but now working towards the HIS framework timescales - report

completed within 3 months

NHS GG&C We use a 3 month indicator to set up the intention of completion in a reasonable

timescale to track progress. Some are completed sooner, some are delayed. Any that

breach over the 3 months are reported to the Board with an explanation. All are

tracked. Data could be produced if required to show the timescales.

NHS Grampian We do not have data to support an actual number, there tends to be a variety of

reasons why some reviews take longer than others. Generally speaking the H&S

reviews are completed fairly quickly and usually within a month. The reviews that take

longer involve cross sectors, so more than one service are involved. The reviews that

need Clinicians, patient /family, staff interviews etc are instigated quickly but take the

longest, we have some at the moment that were started in December 2013 and are

now nearing completion.

NHS Highland Varies from review to review. Since November 2013 we are recording all significant

event reviews on Datix and will be able to monitor the time it is taking to complete our

significant event reviews.

NHS Lothian NHS Lothian has established Key Performance Indicators for adverse events, as set out

below (currently being revised in updated policy and procedure to reflect national

framework):

• Major harm or death – review is commenced within 12 working days of being

reported and fully closed within 60 working days

• Moderate – a local review has been commenced within 12 working days of

being reported, and fully closed within 28 working days



• No harm or minor harm – approved within 10 working days of being reported

and fully closed within 20 days

Performance data for each of the KPI is available.

NHS Tayside The NHS Tayside Adverse Event Management Policy advises that the following

timescales must be adhered to:

• Adverse Event to be reported within 24 hours of occurrence.

• Verifier to complete checking process within 72 hours of receipt.

• Local Incident Review to be carried out within 28 days from Date of Event.

• The SCEA should be held within 3 months (90 days) of the event. The final

report should be completed within 5 months of the SCEA being held.

We have data that supports this as all incidents are recorded on Datix with Local

Incident Review information. There is a SCEA measurement plan in place that records

and analyses performance in terms of agreed timescales. The SCEA process is in its

early stages and is under ongoing review.

NHS WI Currently we are not meeting the timescales in our Adverse Event Reporting,

Management and Learning Policy and the average time for completing an adverse

event review ranges from 40 to 150 days. We are in the process of revising our policy

in line with the National Framework for Adverse Events and our timescales are being

reviewed as part of this process.

Data to support our timescales is available on our Datix system as part of our

document control process.

NHS24 30 days.

NWTC We aim for 60 days.

SAS Our policy states 30 days, and we almost never meet this, we have data to support this

for the last financial year.

State Hospital Using 2012 date:

CIRs this varies from 49 to 233 days. The reasons for delays are also monitored and

reported on.

SUIs vary from 56 to 140 – but changes have been made to the SUI process which has

reduced reporting on occasions to within 20 days. This is monitored using MS Access

database.

Data is collected around this.

Analysis Many of the NHS boards have targets for completion of an SAER ranging from around

30 days to 75 days (not always clear whether it was in working days). The actual dates

for completion are reported as having not met targets with completion dates around

150- 200 days post incident.

7. Who is responsible for creating and coordinating adverse event review teams, and

how do they decide who should be in the team and who should lead?

NHS A&A Nurse/Medical Directors are responsible for commissioning reviews. Following this a

Leadership Oversight Group (LOG) meet to review the event, appoint a Lead Reviewer

and discuss appropriate team membership. The administration of the review is

overseen by the SAER Support Co-ordinator. The lead is determined by a rota, ensuring

the incident has not affected their own specialty. The team are chosen for their

relevant expertise again ensuring no involvement of the event.



NHS Borders The Clinical Governance and Quality Team lead on the co-ordination of adverse event

reviewers in partnership with the final approver of the adverse event. CG&Q will

appoint a sponsor for each significant adverse event review under the direction of the

executive team.

NHS D&G The Quality and Patient Safety Leadership Group (QPSLG) decide on the make up of the

review team. The risk facilitator in the directorate under review coordinates the review

with updates to the QPSLG.

NHS Fife An adverse event is reviewed and based on its grading, other relevant contextual

factors and SBAR information received from the operational unit involved, an

executive level decision (e.g. Board Director of Nursing, Associate Medical Director) is

taken to commission a SAER or other type of review. The Clinical Governance Support

Team coordinates the process.

If a SAER is commissioned, an Executive Sponsor is identified e.g. Board Nurse Director,

Medical Director, Chief Executive. To ensure objectivity and avoid conflict of interest, a

Lead Reviewer is identified from out with the department or speciality concerned e.g.

senior clinician or other senior manager with appropriate knowledge, skills and

attributes. Technical support is provided from within the department for practical

purposes or on occasion, provided or supported by the NHS Fife Risk Management

Team.

An initial SAER Leadership Oversight Group (LOG) is convened where confirmation of

roles occurs i.e. Lead Reviewer, Technical Lead, Corporate Coordinator (e.g. Risk

Manager or Head of Quality & Clinical Governance). The need for Subject Matter

Expert and Patient Relations input is also identified at this point.

NHS Forth Valley The level of event would determine who manages the event. This could be from a

Charge Nurse to a General Manager.

For SAERs, the Associate Medical Director, General Manager and Lead Nurse decide on

the Lead Reviewer, Family named contact and Staff named contact for SAERs and

agree the review team with the Lead Reviewer.

For Adverse Events (excluding SAEs), decision will be made at ward/department level,

Line Manager or GM/Service manager, depending on the level of harm, physical injury

and/or loss.

NHS GG&C There is a Commissioner for each review who will decide who the appropriate lead will

be (often in discussion with the CRM). The commissioner can be a General Manager,

Associate Medical Director, and Clinical Director. The lead will then plan who is needed

to help with the review. Each is different.

NHS Grampian Reviews that will fall into the Level 1 review under the national framework will be

commissioned by the senior management team for the sector in which the adverse

event occurred. The review team lead will need to have attended the RCA course as a

minimum standard and the team will be made up of individuals that have an insight to

the issues but are not directly concerned.

Support is available to teams to conduct reviews from the Quality Governance Risk

Unit and also from Health and Safety Dept, we also have topic specialists who are



available to support.

NHS Highland Each of the operational units is responsible for arranging the significant event review

team. The review team lead in usually the operational unit clinical director, senior

consultant and senior manager. It is depended on the review.

NHS Lothian Managers, in line with operational management structures, have responsibility for the

management of adverse events and consequences to ensure appropriate management

and service improvement. Overall operational management responsibility, including

family liaison, therefore rests with the Nurse/Medical Directors for UHS and CH (C) P

General Managers for Primary Care. Managers will be supported professionally by

medical or nursing colleagues at local or board level as appropriate.

Membership of the review team will be dependent on the adverse event. For adverse

events resulting in major harm and death, the relevant senior management team* will

appoint the lead/team members and agree scope of review. For acute services this will

be the acute services Medical/Nursing director (may be delegated to Clinical

Management team), for CH(C) Ps the CH(C) P senior management team and for Single

system services, the lead director.

The review team should reflect the specialisations of staff involved in the adverse

event. For significant events the review lead should be experienced in, and have

appropriate skills to lead a review. It is also valuable to have someone who knows the

relevant unit or department well, though they should not have been directly involved

in the adverse event. Senior management expertise and Senior clinical expertise/

senior consultant and partnership representation.

NHS Tayside NHS Tayside Adverse Event Management Policy advises that Local Incident Review

should be Chaired/Facilitated locally within Directorates where possible preferably by

Head of Nursing or Clinical Service Manager. If this is not appropriate support should

be sought from the Clinical Governance and Risk Management Team.

Significant Clinical Event Analysis - The Medical and Nurse Director will agree whether

a review is required and will contact the SCEA Team, who will provide administrative

support to the process.

Those present at the Significant Clinical Event Analysis may include:

• Board Nurse Director (or nominated deputy)

• Medical Director (or nominated deputy)

• Associate Medical Director for Service

• Associate Nurse Director for Service

• Clinical lead/Associate Nurse Director external to the service

• Relevant Head of Service/Service Manager

• Head of Safety, Governance and Risk

Other staff appropriate to the incident – This can and should include, for example,

relevant Mental Health Staff, Primary Care Staff, General Hospital Staff, Police, Local

Authority, Voluntary Sector Staff, Prison Healthcare Staff and Scottish Prison Service

Operational Staff.



NHS WI Currently Risk Manager/ Health and Safety Advisor are responsible for coordinating

reviews along with our Associate Directors for Acute Services and Primary Care. In our

revised policy this responsibility will be placed with our Medical and Nurse Directors.

NHS24 Clearly outlined in the policy – the associate director of nursing and operations.

NWTC Head of Clinical Governance in conjunction with the Divisional Management Team.

SAS The patient safety group does this nationally and we decide who should be on the

team depending on type of incident. For example if it is Control related we ensure an

expert from control is involved.

State Hospital The Risk Management Team co-ordinate the review process and are involved in every

review.

The Lead Director is appointed when the Terms of Reference are agreed by the Senior

Management Team. The Lead Director influences who are commissioned as reviewers.

This is decided as to the most appropriate person with the skills and knowledge

required to conduct this. Regular updates are provided to the Lead Directors by the

Risk Management Team.

Analysis Commissioning a review Coordinating a review

• Clinical service manager

member of executive team

• Director of operations

• Head of Clinical governance

• Head of nursing

• Nurse/medical director or

associate

Often done via SBAR

• Charge nurse

• Clinical governance team/rep

• General manager

• Health and safety team/rep

• LOG/QPSLG or other dedicated

group for SAERs

• Risk management team/rep

8. Of the last 20 adverse event reviews carried out, how many have included people

involved in the adverse event as part of the review team? In reviews of adverse

events that involved a patient, did any include the patient within the review team?

NHS A&A No one directly involved in the event has been part of the review team. All of the last

20 events have had either patient involvement where possible of a family

representative. None of these have been members of the review team.

NHS Borders Of the last 20 adverse event reviews carried out no staff involved in the event have

been lead reviewers however staff involved in the event are asked to support the

review process though the provision of information and are given the opportunity to

review statements, interview notes and final reports and where used and involved in

round table discussions to explore the circumstances and contributing factors of an

adverse event.

Where appropriate the patient has been given the opportunity to participate in the

review to share their experience, and the conclusions and actions resulting from the

review process are shared with them. We continue to develop our approach to this.

NHS D&G Patients/families views are sought in relation to the review and any questions/issues

are considered by the review team. A nominated member of staff maintains links with

them through the process.



NHS Fife People involved in the last 20 adverse event reviews were included in the review

process but were not members of the review team itself.

Again, where possible and appropriate, patients and family/carers were informed

about and/or involved in the review process e.g. invited to contribute to the review

process, highlight concerns, an identify issues they wish the SAER to consider within its

terms of reference, but not as part of the review team itself.

NHS Forth Valley Most reviews are led by staff not involved in the event and some may include a

member of staff that was involved (in the minority).

Patients/family. Patients who have been involved in an event may be asked for

information or statements as part of the investigation but unlikely to be part of the

formal investigating team.

NHS GG&C It is very rare that the people involved in the event will be part of the review team

doing the investigation but they are part of the review process. They will be

interviewed and statements taken, they will be given the opportunity to feed into draft

reports to check they are comfortable with what has been portrayed but we would

find it strange for staff or patients to be investigating their own event. They do

contribute to the investigation but that is not the same as being part of the review

team. We believe the review team should be independent of the event and this is our

policy position.

NHS Grampian To the best of my knowledge we have not yet included patients in the review team

itself although we are routinely contacting patients/ families and asking for their input

and also asking what they would like to know/find out as a result of the review. We

advise areas not to include staff in the review team if they have been involved in the

adverse event, they will be involved in the review process however.

NHS Highland Those involved in the adverse event are invited and attend the review meeting. The

chair of the review team is independent. It is the Board’s policy not to invite the

patient or representative to the actual review meeting. The chair of the review team

meets with the patient or their representative before and after the review meeting.

NHS Lothian Of the last 20 adverse events reviews no one who was involved in the event was part

of the review team as per policy. In reviews that involved a patient, no patients were

part of the review team.

NHS Tayside Within NHS Tayside ALL incident reviews should be a multidisciplinary team reviews.

Patients are currently not invited to attend or contribute to Local Incident Review.

SCEA

Patients are not invited to attend the review; however, Patients/Families/Carers are

given the opportunity to contribute to the SCEA. This is done through either a meeting

or telephone conversation in which they can raise any concerns or questions. This in

turn will be raised on their behalf at the SCEA and answered through the SCEA report

where appropriate. Following the finalising of the SCEA Report

Patients/Families/Carers are offered a copy of the Report and the opportunity to meet

with the SCEA Chair.

In the case of ALL adverse events the NHS Tayside Policy states:

Patient/Family/Carer



A full, frank and factual explanation must be shared with the patient at the time of the

incident. For particular patient groups, e.g. children, ventilated patients or vulnerable

adults, this may not be possible. In these circumstances discussion with carer, guardian

or relative is appropriate. In all other circumstances incidents should not be disclosed

to the next of kin, carer or GP etc without the patient’s consent.

This should be done by a team of at least 2 staff members including a clinician who has

a pre-established relationship with them with a clear team leader identified. State

what happened, why it happened and what is being done to prevent it from happening

again (IHI, 2010). Address any concerns the patient and/or family have as soon as

possible. This team should inform patient and family as soon as the organisation has

any new information pertaining to the event.

NHS WI All our adverse event reviews include participation from people involved in the adverse

event. Depending on the adverse event being reviewed we do involve patients and

their families or if family request they can be represented by a member from our local

Patient Advisory Service.

NHS24 None

NWTC All adverse event reviews involve the people involved.

SAS None. We have not done this yet but we do want to further engage staff in this process

and do intend to do this in the future. Families are not involved in the review team;

however we give them the opportunity to ask questions for the team to answer.

State Hospital This would not normally be done at The State Hospital. The incidents reviewed are not

the same as an adverse event occurring within acute or primary care services. Staff

involved in the incident is interviewed as a matter of course if they are available,

however they are not routinely included in the review team.

We may where appropriate discuss the incident with the patient, but this is at the

discretion of the patient’s RMO.

Analysis Generally members of staff and patients/families/carers involved in the incident are

not included in the review process itself, however all responses state that the staff

members and patients/families/carers provide statements etc. Although, NHS

Highland, Western Isles and NWTC invite staff members who have been involved in the

incident to attend the review team meeting.

A few NHS boards note that they have a dedicated family liaison person within the

review team.

9. Do you have a record of the staff involved in significant adverse event reviews in the

last 12 months, including members of the clinical governance/risk management

team? (Please respond yes or no.)

NHS A&A Yes.

NHS Borders Yes.

NHS D&G Yes.

NHS Fife Yes.

NHS Forth Valley Yes.

NHS GG&C Yes – not so east to extract from Datix but it is written at the start of every report who



the review team were and each report attached to Datix.

NHS Grampian For the staff on the clinical governance / risk team yes, we keep a note of who has

supported and what a level of support was required. In the sectors the staff involved in

the review would be identified on the report template and we could if necessary do a

search but we do not keep a record of this as such.

NHS Highland No not held centrally. Locally there will be records of those who attend.

NHS Lothian Yes – this is recorded on the standard template for Significant Adverse Events or on

Datix for other reviews.

NHS Tayside Yes.

NHS WI Yes.

NHS24 Yes.

NWTC No.

SAS Yes.

State Yes.

Analysis Of 15 responses:

• 11 have a record

• 3 do not have a central record, but could pull these out from each report

• 1 does not have a record

10. What are the main challenges you face in terms of developing capability and

capacity for significant adverse event reviews

NHS A&A Capability does not appear to be a major problem, however capacity is a problem in

terms of the amount of hours a review can take out of a staff members working days.

NHS Borders - Capability is dependent on practicing the skills and having experience of being

involved in reviews on a regular basis; this is problematic with other work priorities

therefore sustaining and increasing skills is difficult.

- Capability of individual reviewers in undertaking their roles is not quality assessed or

monitored for skill levels.

- Capability to undertake reviewer role is not included within job descriptions or work

priorities.

- Getting balance right between experienced and new reviewers being involved in

SAER is difficult

- Sponsors/chairs/reviewers require support from specialists (clinical governance &

quality and risk & safety) this resource is extremely limited in numbers of specialists

available.

- Capacity of managers/staff involved in SAER is dependent on work priorities;

sustaining service is the priority

- Finding time to consolidate reviewer skills within the core roles of those trained to

carry out reviews

NHS D&G Releasing staff to attend training/conduct reviews and maintaining/developing

knowledge and skills when they may infrequently conduct a SAER.

NHS Fife • Maintaining clear professional leadership across all groups of staff, securing

robust clinical and managerial engagement in the process, and ensuring there is

an appreciation that such reviews are an organisational priority and

fundamental to improving the quality and safety of healthcare.

• Ensuring that the organisation enables managers and clinicians to participate



fully in SAER. E.g. For senior managers or clinicians; the Lead Review role is

considered an integral part of the job.

• Providing staff with sufficient opportunity to gain exposure to the SAER

process, to support them to undertake key roles and to develop confidence and

competence in undertaking reviews

• Time

NHS Forth Valley Availability of the team members to meet. Work pressures and fitting into job plans.

Limited admin support

NHS GG&C Supporting the number of events we have. The process is time consuming and can be

slowed up by many things out with the investigators control such as delays in getting

notes, waiting on PM results, negotiating meeting times with clinical staff who have

little diary time, availability of union reps who are to accompany interviews, expert

reviews etc.

NHS Grampian The level and grade of staff that will be involved in the category I reviews already have

a wide remits, in terms of developing capability the opportunity to develop skills on a

modular basis, potentially using online resources would be helpful as staff are finding it

increasingly difficult to be absent from the physical work environment. The national

framework help in terms of clarity as has the national programme of improvement as

this has raised the profile of learning from adverse events, however, conflicting

priorities is a challenge. Staff are becoming increasingly burdened by the various

bodies that they report externally to, gather information for and a challenge is how we

can engage them in the process of learning as opposed to putting them off by creating

more administration.

NHS Highland Time constraints

Recently a SER learning event was held and during the event issues re capability and

capacity were discussed.

Staff identified the need for hot and cold debrief (no training provided at present)

Training for chair of SER review team

NHS Lothian Time for the clinical commitment of consultants, the need to allow trained staff to

shadow team members to gain experience, the conflict of providing patient care and

the review responsibilities.

NHS Tayside Ensuring that appropriate Panel members in terms of seniority and independence is

standard and consistent. In addition, training and support needs to be provided to the

Clinical Governance and Risk Management Team involved in co-ordinating, supporting

and administrating the SCEA.

NHS WI The main challenges we face are time, staff availability and lack of admin support. Staff

availability is particularly difficult when our medical staffs are involved and is one of

the main reasons we are not completing our reviews within the timescales stated in

our policy.

We also face remote and rural challenges and sometimes have to rely on video link

support (which brings its own challenges) as staff work on and cover different islands.

NHS24 National training.

NWTC In a smaller Board the key issue is getting the size of the review pool correct. We do

relatively few IR’s / SAE’s so too many staff means they have the potential risk of being

‘de skilled’. The new IR guidance framework may help in so far as we can train larger

numbers of staff for Cat 2 events and keep a smaller pool for Cat 1.



SAS The main issues we have is capacity of the central team to co-ordinate the processes.

State Hospital Timescales and current diary commitments. There has also been a significant increase

in enhanced reviews over the past year.

Analysis Capacity Capability

• Amount of time a review takes the

review staff away from work

priorities

• External delays e.g. Procurator Fiscal

• Limited admin support

• Releasing staff to attend training

• Time taken to co-ordinate centrally

• Challenge of remote location

• Conflict of providing patient care and

review responsibilities

• Debrief/SAER chair training required

• Dependant on practicing skills, avoid

becoming “de-skilled”

• Difficult getting balance between

experienced and new reviewers

• Difficulty in getting specialist support

• Ensuring seniority and independence

of review team

• Maintaining clear professional

leadership across all groups of staff

• Not a problem

• Reviewers skills are not quality

assured

• Reviewing is outwith job description

11. How does the information from you adverse events reviews inform your local

improvement programmes, including SPSP?

NHS A&A All Significant Adverse Event Reviews are reported through the Healthcare Governance

Committee and then cascaded through the appropriate governance committees. These

reports are considered as are the safety information sources.

NHS Borders The workstreams of safe, person centred and effective care are all co-ordinated

through the Clinical Governance and Quality team which provides significant

opportunity for alignment between the proactive and reactive quality and safety work.

There are core clinical groups established to progress priority workstreams of the

safety programme and recommendations from SAERs pertaining to those areas is

channelled into their work.

Safety related SAERs are channelled through the Occupational Health and Safety

(OH&S) Forum to ensure the Clinical Boards and Support Directorates include any

improvements in their OH&S Intervention Plan (improvement plan).

NHS D&G The themes are considered for inclusion within Patient Safety programmes.

NHS Fife Clinical Governance and Risk Management managers input to the QI Hub

A concerted effort is being made to drive learning and improvement from adverse

events. We are testing linking this information with that from other data sources

including complaints and mortality reviews, in order to indentify themes of learning

and improvement.



Reducing Harm Action Plan:

Recommendations and actions from adverse events, complaints and mortality reviews,

including those from SPSO reports, are captured in the Reducing Harm Action Plan.

Responsibility for each action is allocated to an individual.

Monitoring of progress in relation to actions completed is done at Directorate/ Service

level as well as through the NHS Fife Adverse Events Group and the NHS Fife Quality,

Safety and Governance Group.

Composite Clinical Governance Report:

We recognised that operational delivery units require access to timely and meaningful

data in order to drive learning from adverse events, translate learning into

improvements and increase ownership for action. To enable this process, a report has

recently been developed for the units. This contains composite data on adverse events,

complaints, mortality and reducing harms actions.

The report provides delivery units with vital performance data, highlights areas of

concern requiring targeted action, and over time will identify good practice and

improvement.

We introduced this report in October 2013 with one Directorate in the Acute Services

Division. The report has evolved and has now been rolled out to all ‘acute’

Directorates: Reports for CHPs will follow in the coming months.

This information from adverse events and reviews is used to inform and drive

improvement e.g.

• Falls Prevention

• Documentation review

• Tissue Viability - SPSi targets on pressure ulcers

• Venous thrombo-embolism (VTE)

• Capacity and flow

• SABs

• Equipment procurement and standardisation

• Resuscitation training

Board Quality Healthcheck:

A Quality Health Check Report was introduced in December 2013 with the second

report submitted to the Board in February 2014. This describes performance under the

quality ambitions of safe, effective, person centred care in relation to key

organisational priorities including harm free care, healthcare associated infection, A&E

waiting time targets, referral to treatment, readmission rates and falls.

The Health Check report is further contextualised by use of a Patient and Staff story.

NHS Forth Valley SAER actions and learning discussed at Unit Clinical Governance and the Clinical

Governance Working Group.

NHS GG&C All the recommendations from the SCIs are tracked. All are discussed at various levels

of Clinical Governance meetings. Some feed specifically into special interest groups



who also look at SPSP data so for example at the VTE group they would receive any

reports of significant clinical incidents involving a VTE event and the SPSP VTE data is

also looked at. They would look at the recommendations of the event and discus how

this could be met through the improvement programme. Similar is done with other

reports such a Blood Transfusion committee, Infection Control, Fall etc.

Sometimes a local improvement plan is developed on the back of an incident that is

not related to SPSP but is recognised as an area requiring improvement. For example

following an incident involving a miss-placed naso-gastric tube a working group was

established to develop naso-gastric care plan and processes to reduce error.

NHS Grampian Currently we are not fully utilising adverse event reviews to support the SPSP however

we are looking at coding the deteriorating patient arrest calls on Datix and then plan to

do RCA on each of them to determine where the procedure is not being followed and

why this might be.

Other programmes within the SPSP do interrogate date to highlight specific patient

safety concerns and will involve the local facilitators in improvement work, this is

happening in both the mental health and maternity work streams.

NHS Highland Adverse event reviews are shared with teams who are undertaking improvement work

through Highland Quality Approach (Lean), Need to improve our mechanisms for

sharing with SPSP programmes. Information is available and can be accessed.

NHS Lothian The Clinical Governance & Risk Manager reviews all events for themes and trends and

feedback is given to the relevant improvement programmes.

NHS Tayside Learning from adverse event reviews are discussed a local Clinical Governance & Risk

Management meetings and then subsequently escalated to Directorate meetings and

then formal reports to CQF. The Improvement and Quality Committee review all SCEAs

completed at every meeting. In addition, summaries of SCEA reports are shared at CG

forum meetings.

The Associate Director for Patient Safety attends the weekly Clinical Risk Management

meetings with the Nurse and Medical Directors.

NHS WI We have used information from adverse events to inform our medicines management

forum. Another example is learning from an incident relating to a patient who

developed sepsis. Additional training was provided to staff and actions were

incorporated into existing action plan for the hospital concerned. We have also used

learning from falls adverse events to inform local improvement programmes.

All our operational managements teams and clinical governance groups have Risk

Management which includes adverse event management and learning as a standing

agenda item at their team meetings and action plans are developed/ updated and

monitored meetings.

Incident Reporting including adverse events is discussed on SPSP leadership walk

rounds.

NHS24 All info is incorporated into algorithm of changes, and into training.

NWTC Although we keep a central pool of learning and address discreet improvements we

could improve how we triangulate analysis of outcomes and learning to drive



improvement more broadly.

SAS We have a thematic learning action tracker which we monitor to ensure actions are

being progressed.

State Hospital Risk Management are the lead for the SPSP as well and this department also co-

ordinates all adverse event reviews, this is the current link.

Adverse event reviews are discussed at SMT and also at the appropriate governance

committee. Actions arising are assigned normally to a Director and timescales are

allocated for completion.

Should any trends be identified then this would be considered as to the appropriate

method to review this including involving the SPSP group.

Analysis • All actions from SAERs are tracked to completion, thematic learning action trackers

used

• Core groups to address work streams and related recommendations

• Feeds into training

• Linking this information with other information sources to identify themes for

learning and improvement

• Local improvement programmes developed as a result of a SAE

• Reported to senior clinical governance committees then cascaded

• Shared with Occupational Health forums

• Themes fed into patient safety programmes, and other related improvement

programmes

• Used as safety information sources

Expert reviewer network

1. How well equipped does your board feel to carry out significant adverse event

reviews?

NHS A&A Following the in-depth review by Health Improvement Scotland and the subsequent

creation of a comprehensive guidance document and bespoke electronic system, NHS

Ayrshire & Arran are fully equipped to carry out reviews.

NHS Borders NHS Borders have done a significant amount of work in the last year to strengthen

and develop capacity and capability within the organisation. The focus at the moment

is on consolidating that theoretical training provided last year for reviewers and

review sponsors. There is a clearer focus on roles and responsibilities for SAERs as part

of the documentation which has been updated in the last year which gives greater

clarity across the organisation. While still developing we feel good progress in being

made in this area.

NHS D&G Capability is developing.

NHS Fife We feel we are quite equipped to carry to carry to such reviews but must continue to

develop and sustain a pool of staff with appropriate knowledge, skills and attributes.

NHS Forth Valley Fairly well equipped but moulding the process with learning from each review. Still

developing and training staff to undertake SAERs

NHS GG&C We feel well equipped. Given the scale of the Board SCIs occur reasonably frequently

so a good level of experience can be built up and there are a number of experts who

have been performing reviews for some time. We also have a robust policy that

provides good guidance to the investigation team.



NHS Grampian There is variable standard in the review process since the HIS review report and

recommendations we have been working hard toward taking a consistent approach

and there has been improvement. We have used a peer review tool on occasions to

look at the completed review reports, and have tested it on PDSA format; however

this is currently not in use throughout the organisation.

For reviews that have staff forms the governance and risk teams on the team the

standard is high and the review report is readily available on Datix.

NHS Highland Fairly well equip as it we have an agreed process which is followed by the Operational

Units. The chair of the review team as normally the Operational Unit Clinical Director.

NHS Lothian There is a number of staff with specialist skills and experience to carry out significant

adverse event reviews and our approach, as described in the previous section is to

build capacity and capability within the service. The current focus on facilitating team

training, tailored to specific staff groups further supports this aim.

NHS Tayside Well equipped.

NHS WI NHS Western Isles has invested in providing training on carrying out adverse reviews

and Root Cause Analysis training will be included in our Risk Management Training

prospectus for this year.

Following the publication of the National Framework for Adverse Events we are

revising our Incident Reporting, Management and Learning Policy and we are also

keen to develop our systems and processes once the work of the 4 groups established

to take the National Framework forward has been concluded.

NHS24 Well equipped – senior staff

NWTC Well equipped. There is a small but well trained team who can lead and facilitate such

events.

SAS We feel we are building the necessary skills within the Service to carry these out, the

main concern we have is that we are not fully identifying the human factors elements

of the incident.

State Hospital Very well equipped for our environment.

Analysis Of the 15 NHS boards:

• 5 felt that they were very well equipped

• 10 felt that were still developing but with progress being made

2. What do you consider are the key skills required to lead such a review?

NHS A&A The key skills attributes are:

• Listening

• Analytical

• Leadership

• Time Management

• Specialist knowledge

• Positional relationship to ensure viewed as competent and having authority

NHS Borders Personal skills: Logical thinking with an inquiring mind, ability to follow the evidence

and ask the difficult questions, tenacious and patient, a decision maker, good

communication skills.



Professional skills: Leadership skills. Knowledge of the root cause analysis process,

ability to choose and apply the reviewers tool kit, adapting these where required. An

understanding of the legal implications.

Skills in root cause analysis, statement taking, investigate interviewing, report writing,

public engagement and complaints handling, facilitation and chairmanship skills.

NHS D&G Tenacity – desire to get to the root cause(s). Ability to deal with complex

information/analysis. Ability to lead team. Degree of independence from operations.

NHS Fife Appropriate level of clinical/managerial expertise, credibility, seniority, authority

Positive and constructive attitude to adverse event reviews

Knowledge and skills in human factors, RCA/ other investigative methods

Commitments to learning and improvement

Ability to:

• Maintain a balanced, inquiring and objective perspective

• Exercise scrutiny, rigor and a methodical approach

• Excellent communication and report writing skills

• Subject matter expertise

NHS Forth Valley Enquiring mind, knowledge of RCA tools, guiding the team and ensuring evidence

decision-making

NHS GG&C • Understanding of the policy, process and requirements of an investigation.

• A robust knowledge and understanding of RCA and human factors.

• Organisational and time management skills.

• Report writing skills.

• Interview techniques that encourage participation in the process and are seen

as supportive rather than punitive.

• Confidence, assertiveness and authority to ask difficult questions and

persistence to establish the root of the issue.

• Ability to link causation with the recommendations.

• Ability to write realistic achievable recommendations.

• Ability to gain an understanding of the context and any technical information

that is pertinent.

It appears easier for individuals who naturally have operated a more pronounced

logical framework to complete these investigations.

NHS Grampian • Need to have a working knowledge of the related issues, i.e. if it is

predominantly a clinical issue the lead would need to be a clinician/or there

would need to be a clinician on the team.

• Need to be suitably removed from the individual case to ensure there is

transparency.

• Need to have an open enquiring attitude toward fact finding.

• Non judgemental and organised, need to keep oversight of progress, take a

systems approach and avoid blame a minimum standard i.e. RCA trained and

will have completed several reviews as a team member rather than lead.

• Will also need to have capacity to conduct the review and access to support

i.e. administration would need the authority from the organisation and the

organisation would need to make it clear that this is a priority.



We are introducing training on being open and it would be expected that leads would

have attended this also.

NHS Highland • Facilitation Skills.

• Dealing with disagreement.

• Ensuring that everyone feels comfortable in speaking openly about the

incident.

• Able to meet with patients and families who are often distressed, grieving etc

NHS Lothian • Effective communication skills.

• Interview skills.

• Analytical skills.

• Appreciation of how human factors come into play,

• Listening skills,

• Appreciation of task need, team needs, and individual team needs.

• Project management to ensure that review is completed within a given time

frame.

NHS Tayside Facilitation skills, in-depth knowledge of RCA tools, Human factors, Care management

problems.

NHS WI • Communication skills

• Organisational skills for establishing review teams, arranging meetings, setting

agenda, note taking and ensuring feedback given to staff, patient,

relatives/carers if they are involved.

• Time Management skills

• Report Writing skills

NHS24 Knowledge of human factors and RCA

NWTC Aside from the understanding of the key principles of investigation, leaders of such –

process must have well tuned communication skills and remain objective in situations

where it is easy to pass judgement.

SAS Expert reviewer skills and the ability to lead a team to ensure true system and human

factors are identified.

State Hospital Impartiality and the ability to understand the difference between human error and

policy/procedural issues.

Analysis • Analytical

• Assertive

• Commitment to learning and improvement

• Communication

• Decision-maker

• Facilitation/Chair

• Independent

• Inquisitive/open mind/non-judgemental

• Interview techniques

• Leadership

• Listening

• Logical

• Patient

• Policy awareness

• Positive/constructive attitude



• Report writing

• Research

• Seniority/authority

• Specialist knowledge e.g. RCA and other investigation methods

• Statement taking

• Tenacious

• Time management/organisational

3. What training and ongoing development do you provide to build skills required to

implement and learn from significant adverse event reviews?

NHS A&A There is no specific ongoing training. Individuals have personal development plans

which would build in any identified requirements to be addressed.

NHS Borders We are trying to develop a learning approach within the organisation and have been

using patient stories to support this approach; such stories are presented to our Board

at their regular meetings and are being captured for use across the organisation.

Often these stories originate from complaints and we intend to widen this to include

stories from SAEs. Individual cases are used as part of learning and teaching with

clinical groups. This is an area we plan to continue to develop and is a priority for us

this year.

Training: Leadership training 1st

Line Management training. Risk Management for

Managers, Risk assessment skills, stress management skills.

NHS D&G RCA training and refresher courses. Human Factor causes.

NHS Fife Adverse event review using RCA methodology.

NHS Forth Valley Learning is building currently and we are trying to merge learning into themes which

may require to be addressed at am organisational level.

NHS GG&C This question is confusing, not sure the answer below is what you are looking for.

Skills to enable one to implement a review:

Following RCA training we take note of individuals who would like to shadow an

expert reviewer to gain experience. Clinical Risk Staff also supervise new reviewers

and are available for advice at any point of the review process. There is feedback from

the QA processes that operate (see Q5)

NHS Grampian As above investigation skills RCA and soon to include being open generally speaking

the review lead will have conducted previous reviews, and often in the serious (Level

1) reviews there will be a degree of support from governance and risk staff or health

and safety staff.

NHS Highland Nothing at the moment but reviewing.

NHS Lothian As described previously, there will now be a focus on training investigation teams, and

specific training tailored to suit the needs of the service. Currently working on

developing workshops for Mental Health, Substance Misuse, and for Maternity

Teams.

Report writing skills have been delivered as a pilot project with future developments

to form a comprehensive training package.

NHS Tayside Please see question 3 in capacity and capability section of questionnaire.



NHS WI This will be considered when our revised policy is approved and risk management

training will be provided when it is launched as the process for conducting adverse

event reviews is changing quite significantly. Training requirements of staff

conducting reviews will be identified and training and ongoing development will be

agreed with staff.

NHS24 Ongoing development within the CG team.

NWTC See above.

SAS Training highlighted above.

State Hospital Our outstanding actions are monitored by the Risk and Governance (RAG) Committee

and Senior Management Team, therefore any identified as a recommendation is

pursued in this manner. The Learning and Development department review all

CIRs/SUIs in terms of any identified learning requirements.

We are also taking forward sharing the outcomes of these reviews with the Forensic

Network to ensure broader learning is shared.

Analysis • Human factors

• Line management training

• Patient stories

• RCA (and refresher)

• Report writing skills

• Risk assessment

• Risk management

• Stress management

4. How are significant adverse event review findings fed into the governance of the

NHS board?

NHS A&A Following approval of the report by the LOG consultation with family and staff, the

report is submitted to the Board’s Healthcare Governance Committee for onward

cascade via the directorate governance groups.

NHS Borders Each concluded SAERs is considered by the relevant clinical board/support service

governance groups and is fed from that group through the organisational wide

Healthcare Governance Steering Group through to the Board Clinical Governance

Committee. Each governance groups has responsibilities to ensure actions and

recommendations are followed up.

NHS Fife SAER findings are shared with the clinical and managerial teams and via the clinical

governance structures at operational unit, division and Board level.

NHS Forth Valley Findings are taken to Unit Clinical Governance/Risk management and Clinical

Governance Working Group for wider learning. Progress and key themes are taken to

the Clinical Governance Committee

NHS GG&C Clinical Governance Meetings at various levels in the organisation.

Also within aggregate incident reports. 2 monthly board reports on SCIs and ASEMs

(never events). All recommendations tracked and pursued until completed – tracking

system in place.

NHS Grampian Leaning is fed to the local sector governance group and via the sector reports to the

NHSG Clinical Governance Committee (CGC). Sometimes the sector will be asked to

send representatives to speak to the review report at the committee. All sectors have



a governance representative at the CGC. The committee receives regular agenda

items covering incidents focussing on the trend data and improvements in processes.

They receive a joints incidents complaints and claims.

The Staff Governance Committee regularly reviews incident data focusing on trends

and improvements for example the statistical analysis of staff related incidents from

Occupational Health and Safety\ Committee.

NHS Highland At every Clinical Governance Committee meeting there is a report on all significant

events that have been report and action taken. These reports are being improved to

show what action is being taken and that this is being completed. At every Clinical

Governance Committee a patient story is used and this may be a significant event

review.

Each of the operational units discusses their significant event reviews at their Quality

and Patient Safety Groups.

NHS Lothian The clinical Governance & Risk Management reviews all significant adverse events for

themes and trends and for compliance with policy procedure. This information is def

back to the board via the Healthcare Governance Committee. Relevant individual SAE

reports are also reviewed by the committee by exception.

NHS Tayside • Improvement & Quality Committee

• Clinical Quality Forum

• Locality CG Groups

• Executive Management Team

• Board Meetings

NHS WI Findings and learning from reviews are given to Governance leads to table at Clinical

Governance meetings. A quarterly incident report including adverse events is

produced from information held on Datix Risk Management Reporting System and is

disseminated to management teams and Clinical Governance Groups. A summary of

serious adverse events reported is a standing agenda item at our Healthcare

Governance Committee meetings.

As part of our incident report we include learning. Action plans are being monitored

by local Clinical Governance Groups.

NHS24 Structured approach- regional and national groups then to clinical governance

committee.

NWTC All SAE are table at the CGC via governance.

SAS Reports presented to CGC, SMT and staff governance.

State Hospital All CIR and SUIs are reported to RAG and Clinical Governance Committee. They are

also discussed at Health & Safety Committee and the Medical Advisory Committee.

They are also published on the hospital intranet in a redacted form.

Analysis Of the 15 NHS board responses:

• 5 report to a specific SAE group initially

• All report to their clinical governance committee (or similar)

• 3 report to the Board

All reported that the information shared with these governance groups are to be

cascaded throughout the organisation.



5. How does your NHS board measure the quality of significant adverse event reviews

and how is the learning fed back in to service improvement?

NHS A&A There is a report template used. In addition, patients/relatives, staff and team

members are surveyed to identify any issues.

The learning is fed back through governance groups and feedback to staff directly

involved in the adverse event.

NHS Borders We are currently looking into how we can do this effectively with a focus on sharing

learning and follow up implementation of action resulting from SAE reviews.

NHS D&G Not formally measured. The Quality & Patient Safety Leadership Group act as quality

assurance mechanism.

Actions planned are agreed with service managers and reviewed quarterly.

NHS Fife SAER reports are measured against a Quality Assurance (QA) Checklist. Copy is sent to

Lead Reviewer.

Feedback is also contained in the notes of the Leadership Oversight Group associated

with the SAER.

NHS Forth Valley Awaiting feedback from the national review of how we are to share the learning.

NHS GG&C Acute – all SCI reports are quality assured by a CRM and signed off by the

commissioner. There is also a sign off checklist that can be used to check everything

has been performed correctly.

Mental Health Services – QA group who review all reports.

NHS Grampian We currently do not have a formalised measure. Learning is fed back via a variety of

mechanisms and groups, the acute sector has a meeting every 2 weeks called the

shared learning meeting, and this included learning from incidents and complaints.

M&M meetings team meetings Obs and Gynae have a weekly learning meeting over

lunchtime. Reports are circulated by specific groups i.e. The Protecting Children

Group.

We distribute shared learning notices via Datix.

NHS Highland No not at the present time, however we are reviewing our mechanism to ensure

learning is shared across the Board.

Standardised process dealing with significant adverse events. Modified the Datix

incident management system to record elements of our SER process. Using the action

module of Datix to capture actions arising from the SER.

Reports are prepared on a quarterly basis for each of the operational units and for the

clinical governance committee/health and safety committee. This includes specific

information on SERs. Use the dashboard module on Datix.

Ad hoc reports are prepared as part of the background information for the lean

projects being undertaking across the Board.

NHS Lothian The Clinical Governance & Risk Manager reviews all significant adverse events for

themes and trends; this information is fed back to the service and to the board via the



Healthcare Governance committee.

NHS Tayside For quality checking Local Incident Review, NHS Tayside has developed a quality tool

which has already been tested and modified. To be rolled out.

For Significant Clinical Event Analyses – draft reports are sent out to both the panel

and attendees for accuracy and agreement on recommendations prior to final sign

off.

NHS WI As part of our quarterly incident report we include thematic learning and this

information is disseminated to our Management Teams and Clinical Governance

Groups.

Action plans are monitored by our Clinical Governance groups to evidence services

improvement.

Monitoring will be reflected in our revised Incident Reporting, Management and

Learning Policy.

NHS24 All info is incorporated into algorithm of changes, and into training.

Quality – Don’t know.

NWTC This is not something we currently do.

SAS Each report is presented to our patient safety group for review and the medical

director will now be sent the final drafts for quality assurance. We collect themes

from incidents and ensure there is work nationally to take these risks forward.

State Hospital Post review questionnaires are sent out to staff involved in the process. These are

reviewed by the Risk Management department and actioned as required.

Staffs bulletins are produced to ensure all staff are aware of finding of reviews.

Analysis Measure quality Feedback learning

• Mental health quality assurance

group who review all reports

• No formal measurements

• Not something we do

• Post-review questionnaires to staff

involved

• Quality and patient safety leadership

group act as quality assurance

mechanism

• Quality tool

• Report sign off checklist

• Reports quality assured by clinical

risk manager

• SAER reports measured against a

quality assurance checklist

• Shared with medical director for

quality assurance

• Templates

• Actions are agreed with service

managers, reviewed quarterly

• Ad hoc reports prepared as back

ground information for projects

across the NHS board

• Circulate reports from specific

groups

• Collect themes

• Feedback in leadership oversight

group notes

• Feedback to staff directly involved in

a SAE

• Governance groups

• M&M meetings

• Shared learning meeting every 2

weeks (incidents and complaints)

• Shared learning notices via Datix

• Shared with patient safety group for

review

• Staff bulletins



3/15 NHS board reported that they are currently reviewing their

processes/mechanisms.

6. How does your NHS board learn from other NHS boards significant adverse event

reviews, what do you think is the best mechanism for this?

NHS A&A At the moment this does not occur. The previous consultation on this issue identified

a number of potential options of learning from adverse events from other NHS

Boards. All the options will be resource intensive and it is for a national decision to be

taken.

NHS Borders This is not done consistently at the moment as there is no way other than through

informal network to share such information.

NHS D&G No formal mechanism. Published reviews are analysed and learning pints considered

for local context.

NHS Fife No overt existing mechanism . Potential mechanism would be a learning portal.

NHS Forth Valley Learning opportunities appear from a range of sources e.g. Clinical Governance and

Health and Safety as well as speciality colleagues and are shared across NHS FV via an

Internal alert system as well as through the various committees. For example the

MHRA One Liners are distributed this way.

NHS GG&C Suicide review network develops a learning report. No really effective way of learning

from other Boards at the moment. There used to be some sharing at the Risk

Managers Network but since HIS abandoned its facilitation role it disbanded and there

has been nothing to replace it. The NPSA Observatory Reports were an example of

outputs that could help develop appreciation of risks.

NHS Grampian Currently learning from other Boards tends to happen in an informal way at national

gatherings i.e. Liaison co-ordinators, SPSP.

NHS Highland No, perhaps a national bulletin, national annual event to share learning across

Scotland.

NHS Lothian Currently done through the Patient Safety Programme. Going forward, best

mechanism would be through sharing information on themes and trends.

NHS Tayside No system in place at present. National focus groups will help develop this

mechanism. This will also be influenced by the outcome of the Options Appraisal

currently out to all Boards for consultation.

NHS WI Through informal networks, National Publications and Learning from any Fatal

Accident Enquiry reports that are published.

The best mechanism will be the National Learning system once the option is agreed to

take this forward.

NHS24 Currently – informal networks.

Best – national anonymous approach.

NWTC Tends to be through informal discussions. Would value more formality however this

looks.

SAS We don’t, only through national alerts etc.

State Hospital Reports are reviewed and if appropriate, action plans are produced and monitored by

Clinical Governance Committee.



Analysis 13/15 NHS boards reported that there are currently no formal mechanisms in place

for this.

Current mechanisms Potential mechanisms

• Review published reports

• Suicide review network

• Risk managers network before it

disbanded

• Informal networks

• SPSP

• FAI reports

• National alerts

• Anonymous approach

• Learning portal/national learning

system

• National annual event

• National bulletin

• National focus group

• Share information on themes and

trends

7. How does your NHS board evidence independence and accountability for findings?

NHS A&A The Board ensures that the Lead Reviewer is independent to the directorate in which

the event occurred and the subject matter experts have not been directly involved in

the event. The team is approved by the commissioning director.

NHS Borders The local SAER process is set up in such a way that we try and ensure reviewers of

SAEs are from out with the clinical area in which they occurred to bring a degree of

objectivity. Each review also has an executive sponsor to oversee and challenge as

appropriate. We also draw on external reviewers where necessary or when it should

be useful to have an external perspective. Concluded SAERs are linked through the

governance structure of the organisation and Clinical Board/Support Services

governance groups take responsibility for ensuring actions from SAERs are concluded.

We are working to develop robust action tracking systems with Clinical

Boards/Support Services at present to strengthen this aspect of follow-up and

assurance.

NHS D&G No formal mechanism.

NHS Fife For each SAER, a Lead Reviewer is designated from out with the area involved in the

event. An Executive Sponsor chairs the LOG.

Accountability: Following a SAER or other review, the recommendations and actions

are considered at the NHS Fife Adverse Events Group which is chaired by the Board

Director of Nursing or the Associate Medical Director. The Group agree what actions

are to be captured in the NHS Fife Reducing Harm Action Plan (RHAP). Each action is

allocated to a responsible individual and tracked through to completion.

The RHAP is shared with the operational delivery units. Progress is reported and

scrutinised by the Quality, Safety & Governance Group which in turn reports to the

NHS Fife Clinical Governance Committee.

NHS Forth Valley Any staff selected for a review team is chosen to try to ensure complete

independence and competence in the subject.

All staff involved are made aware of their accountability prior to the review

commencing.

NHS GG&C The policy and framework guides the process to make sure it is as non-biased as



possible. The reports also Quality Assured by staff that don’t actually work directly for

the Directorate involved so have a level of independence. Findings are challenged and

called to account at Clinical Governance Meetings so reports require to be robust and

evidence based. The staffs involved in the event have contributed to the investigation

and have the opportunity to comment.

We would also offer that there is transparency through the minutes of the Boards

Clinical Governance Committee who would challenge the Directorate/partnership

Clinical Governance Committee for actions and completion of actions ascribed to the

recommendations made within reports.

NHS Grampian We appoint leads to conduct investigations that are not directly involved in the

incident. We have appointed managers from Moray to reviews incidents that

occurred in Aberdeenshire and vice versa. Staff from NHSG have been asked to and

have supported investigations in other Boards. We now share reports and

recommendations with staff involved and patients/families. Where an adverse event

crosses services the Deputy Chief Operating Officer appoints a lead and the report is

fed back to her directly.

NHS Highland No.

NHS Lothian The Medical Director is the executive with responsibility for the effectiveness of the

incident management system. There is a governance approval process for Significant

Adverse Events sign off which includes approval at Board level, action and monitoring

at service level.

This includes sign off by:

• CH(C)P Director/General Manager/UHS Director of Operations

• UHS Nurse/Medical Director/CH(C)P Clinical Director/ Chief Nurse

• Medical Director

• Nurse Director

NHS Tayside • Governance route for account.

• Panel members from out with service

• Action trackers

NHS WI Through action plans developed following adverse event reviews which have named

people identified who are responsible and accountable for ensuring actions are

completed within agreed time frames. Action plans are also monitored by our Clinical

Governance Groups.

NHS24 Independence – public partner on all governance mtgs.

Accountability – Recommendations assigned senior member of staff.

NWTC The scope of the RCA lays out accountability and reporting arrangements.

SAS We ensure an independent team from the area the incident was involved reviews the

incident.

State Hospital These are reported to Senior Management Team which is minuted and progresses

from agreement of enhanced review to conclusion, followed by the actions arising

from the recommendations made.

Analysis • Accountability of review team set out at the start of review

• Actions assigned to a responsible individual

• Executive sponsor on review team

• External reviewers if necessary

• Governance groups take responsibility for ensuring actions are completed



• Independent (to directorate) lead reviewer

• Medical director is executive with responsibly of incident management system

• No formal mechanism

• Public partner on all governance groups

• Review team approved by commissioning director

• Use of action trackers

8. Are there circumstances where you think it should be mandatory to bring in an

independent reviewer?

NHS A&A No. External experts have been used when it has been identified this would be the

best thing to do, particularly for the individuals with highly specialised knowledge.

NHS Borders Yes.

NHS D&G Not sure.

NHS Fife To date this has not transpired nor have we identified such a requirement. Such

circumstances might be in the event of:

• Homicide committed by a person who is or has been under the care of our

service

• Significant Systemic Service Failure

NHS Forth Valley If this was recommended by the Associate Medical Director and General Manager.

Approval would be sought from the Medical Director and Director of Nursing.

NHS GG&C We have used independent experts for issues where a high degree of technical

knowledge of the subject is required to understand what happened and that staff

with that knowledge in the Board are too close to the event. This is at discretion of

the commissioner – this is not mandatory.

NHS Grampian Could consider some of the child protection, vulnerable adult cases to require

independent reviewers however there will be ongoing challenges related to this with

the emerging work around the Health and Social Care Integration. In cases where the

stakeholders are not satisfied with the outcomes or when they think there has been a

lack of transparency.

NHS Highland N/A

NHS Lothian No. Our current processes work well in that the medical and nursing director review a

weekly list of all adverse events resulting in major harm/death and decide, in line with

our policy and procedure where it is necessary to invite an independent reviewer to

lead the review. This is done within the context of the review, for example, inviting

and independent review from a specialist in that area from another Board.

NHS Tayside Yes.

NHS WI On occasions when there are sensitive and complex adverse reviews to be undertaken

we have tried to ensure independence by requesting external reviews.

NWTC Where there are possible criminal acts. Otherwise each case should be viewed on its

merits.

NHS24 Yes – but can’t say what they would be.

SAS Yes in some cases.

State Hospital Yes, if there are cross board issues or potential conflicts of interest.


• 11 would consider bringing in an independent review in particular circumstances

• 2 would not consider this



• 2 were unsure

• 3 have already done so

9. If an external network were established:

- what would you see the remit of such a network being?

- how would you think such a network should be funded/resourced?

- what would you perceive as benefits/drawbacks?

- what would the risks be of such a network?

NHS A&A Remit – To provide clear guidance and process for all Health Boards to follow

Funded – Government

Benefits – All boards working to the same system, easier sharing of

findings/recommendations/learning

Drawbacks – Inflexibility i.e. ability to complete review dependent on the detail.

Risks – Could be too bureaucratic.

NHS Borders I don’t feel we have enough information on the proposed external network to answer

the questions.

NHS D&G Would need clarity of remit but may act as:

• Independent reviewer of SAER

• A forum to share learning and best practice

• A body to influence health sector policy and practice based on analysis of

recurrent themes

NHS Fife Remit: To provide in depth knowledge and expertise in the review of adverse events

Funded: Centrally funded. Establish cohort of expert reviewers from all Boards. Place

a limit on the number of reviews in which any individual would be expected to work

on per year.

Benefits:

• Expert investigate skills

• Consistent and reliable approach to review

• Freedom to act

• No conflict of interest

• Objectivity and transparency

• Able to establish a repository of data on trends, themes, common care and

service delivery problems, preventative measures/ barriers to inform the

development of policy and guidance

• Develop topic matter expertise on which Boards could draw in e.g. common

casual relationships, risk factors

• Community of practice to support sharing of experience and lessons learned

Risk and drawbacks:

• Feedback to service- possibility of reduced acceptance as from outside

perspective

• Reduces staff ownership and possible loss of knowledge and skills

• Possible lack of engagement and buy in from Boards

NHS Forth Valley Remit -Providing a forum to share the rich learning from SAERs - presentations - not



just the statistics

Funded/Resourced - From outwith NHS Boards

Benefit/drawbacks

- Ready-made pool of contacts for discussion/advice where required

- Improved safety for patients through shared learning

Risks - Concentrating on the stats side more than the absolute rich learning

NHS GG&C Remit - Unsure – perhaps peer-support aimed towards smaller Boards. We are

fortunate in a large Board of having that already within our department but recognise

that others might not have this. We have frequently ‘run things past each other’ or

ask if a colleague has had a similar experience when leading reviews.

Funded/Resourced - There is concern this would increase workload for those who

perform reviews as there is enough workload within the Board without helping to

review incidents in other Boards. We cannot see it progressing on a voluntary basis so

any activities would need to bed backfilled.

Benefits – perhaps another Board have had a similar incident in the past and they can

share what they looked at during the investigation?

Drawbacks – extra work. I also think it would be unpopular with the Boards for their

incidents to be investigated by other Boards.

Risks - No one uses it. It becomes too much work. It is not effective. There is not

enough people on it. The capability of members varies but from past experience it

needs to offer something for those who are more expert otherwise they withdraw.

NHS Grampian Remit - Sharing lessons and best practice. Linking themes. Would prefer it to be a

supportive process, would need to establish who sets the terms of reference, is it the

Board or the external network? What happens to the reports? Would need to clearly

identify what value such a network could bring to the process and how the value

would be measured.

Funded/resourced The network could be made up of staff from each Board, however

capacity is a concern noted by most Boards. The review network could be funded

centrally for a set duration and the value and benefits could then be measured and

evaluated.

Benefits - Benefits would be that reviews would increasingly be conducted in a consistent

format; the learning from the reviews would be anonymised and shared consistently.

Stakeholders would be reassured that due process was being followed.

Drawbacks - Drawbacks include, sustainability succession planning and capacity if Boards are

to provide staff to populate the review network. Expenses/ travelling and poor IT facilities.

Risks - Staff may disengage from the process locally and expect someone to come in and do

the reviews and identify learning for their areas. Staff may also disengage if the review

network is seen as another form of scrutiny. Risks are also as above in terms of capacity

sustainability, releasing staff to perform reviews out with the Board.

NHS Highland Support Board with SER where a specialist is need or when there is disagreement



Contribution from each Board

Sustaining the network, who would you include?

There may be limited pool so who would get priority

Expensive

Provide an independent view

NHS Lothian We consider that it is more important to have a local network for a Board of our size

and to develop capacity and capability locally. External reviews will continue to be

requested where appropriate as in question 8. In this way, the focus on learning

rather than external scrutiny will be retained.

NHS Tayside Remit - Sharing learning from incidents between Boards; sharing of challenges and

successes. Could this be run through HIS as previously done with Risk Managers

Network and current Liaison Coordinators?

Benefits – include learning; benchmarking, opportunities for improvement (saves

reinventing the wheel if we can steal shamelessly from each other – something we

lack at the moment).

Risks – Not everyone will make an equal contribution.

NHS WI Remit - Remit of network will be to coordinate national sharing of learning from

adverse event reports.

Funding - I think there should be central funding made available to support Boards to

develop and implement network.

Resource - It would be beneficial to have Health Improvement Scotland staff available

as a resource to support the network.

Benefits

- All NHS Boards in Scotland will be using the one system to enable shared

learning.

- Consistency in approach for management of adverse events across Scotland.

- Increased safety and more open culture.

Drawbacks - Will there be additional resources available to help existing staff with

the additional work that this will involve.

Risks

- There is a risk of disruption to current Datix System.

- Risk that it will become a number crunching exercise and not be about

qualitative outcomes and improvement.

NHS24 Remit – Supportive sharing mechanism

Funding – Cost neutral

Drawbacks - No drawbacks

Benefits – Supportive of national approach

Risk – People not released from work to attend

NWTC I don’t think an external network should be set up. It should be the job of HIS to

provide this ‘service’.

SAS Remit - To review incidents where the Board feels it doesn’t have the capacity to do

so in house for political reasons etc.

Funded - Funded centrally by Government

Benefits - I only see benefits in this approach as I don’t see the external network



reviewing all cases I just see them doing the one which the Board feel they want an

independent review.

Risks - Risk is that they would be overwhelmed by incidents which should really be

managed locally.

State Hospital N/A

Analysis Remit Funded/resourced

• A body to influence health sector policy

and practice based on analysis of

recurrent themes

• Coordinate national sharing of learning

from adverse events reports

• Forum to share learning/best

practice/themes, not just statistics

• Independent reviewer of SAER

• Peer-support for smaller NHS boards

• Provide clear guidance and process for

all health boards to follow

• Provide in-depth knowledge and

expertise in the review of adverse

events

• Sharing of challenges and successes

• Supportive process.

• Cannot see this progressing on a

voluntary basis, activities would

need to be back-filled

• Centrally, for a set duration then

evaluated.

• Concern that this would increase

workload for those who carry out

reviews

• Cost neutral

• Establish cohort of expert

reviewers from all NHS boards.

Place a limit of number of

reviews in which any individual

would be expected to work in

one year

• Government

• Made up of staff from each NHS

board

• Out with NHS boards

• Run by HIS staff as with previous

risk managers network and

current liaison coordinators



Risks Other points raised

• Ability to release staff to perform

reviews out with their NHS board

• Concentrating on statistics more than

the absolute rich learning

• Could be too bureaucratic

• Disruption to current Datix system

• It becomes too much work

• It is not effective

• No one uses it

• Not everyone would make the same

contribution

• People withdraw due to not gaining

anything from this

• Possible lack of engagement and buy-in

from NHS boards

• An external network should not

be set up, HIS should provide this

support

• Ensure contribution from each

NHS board

• It may be more beneficial to have

a local network for larger NHS

boards and to develop capacity

and capability locally. This will

focus on learning rather than on

external scrutiny

• What happens to the reports?

• Who would set the terms of

reference, NHS boards or

external?

Benefits Drawbacks

• Able to establish a repository of data on

trends, themes, common care and

service delivery problems, preventative

measures/barriers to inform the

development of policy and guidance

• Allow NHS boards to use network for

cases which the NHS board feel they

need an independent review

• Benchmarking

• Community of practice to support

sharing of experience and lessons

learned

• Consistent approach to review

• Develop topic matter expertise, ready-

made pool of contacts for

discussion/advice where required

• Easier sharing of review focus/

findings/recommendations/learning

• Expert investigation skills

• Freedom to act

• Improved patient safety through shared

learning

• Learning and sharing anonymously

• No conflict of interest

• Objective and transparent

• Opportunities for improvement, share

processes/tools to save repetition

• Reassurance for stakeholders that the

correct process was being followed

• Expenses/travelling costs

• Expensive

• Extra work

• Feedback to service – possibility

of reduced acceptance as from

outside perspective

• Inflexibility

• None

• Poor IT facilities

• Reduces staff ownership and loss

of knowledge/skills

• Staff capacity already stretched,

sustainability

• Unpopular with NHS boards for

other NHS boards to review their

incidents



• Staff capacity and sustainability

• Staff may disengage if the work is seen

as another form of scrutiny

• Staff may disengage with the process

locally and expect external reviews to do

the work

• There are not enough people on it

• There may be a limited pool of

reviewers, how would get priority?

• Will there be additional

resources available to help

existing staff with the additional

work?

• Would need to identify what

value such a network could bring

to process and how the value

would be measured



‘Never events’ questions

Description of ‘never event’:

• The incident has clear potential for or has caused severe harm/death.

• There is evidence of occurrence in the past (i.e. it is a known source of risk)

• There is existing national guidance and/ or safety recommendations on how the event can be prevented.

• The event is largely preventable if the guidance is implemented.

• Occurrence can be easily defined, identified and continually measured.

1.

1a.

1b

Does your NHS Board collect information on any type of ‘Never Event’ list?

If yes: Is this a list from the NPSA or your own constructed list? Please provide

the list you are currently using. (continue with question 2)

If no: Is there a reason you do not currently do this or do you like the idea and

are planning to implement something? (please answer 3a)

NHS A&A NHS A&A has a number of events that have to be escalated (currently being

reviewed). These are categorised as:

• Unexpected death

• Significant harm to a patient and family

• May have required intervention to save life

More detailed lists were generated from these headings as follows:

Events that should never happen

• Surgery performed on the wrong body part

• Surgery performed on the wrong patient

• Wrong procedure performed on a patient

• Unintended retention of a foreign object after surgery or a procedure

Unexpected events related to care and treatment that have caused death,

significant harm or required intervention to save life

• Unexpected anaesthetic , intra-operative or immediate post operative

death

• Medication error – wrong drug, wrong dose, wrong patient, wrong time,

wrong rate, wrong preparation or wrong route of administration

• Haemolytic reaction due to the administration of incompatible blood

• Unexpected significant hypo or hyperglycaemia occurring in the

secondary healthcare environment

• Grade 3 and 4 pressure ulcers acquired in hospital with no previous skin

problems

• Unexpected death from sepsis

• Venous thrombo-embolus acquired in hospital where prophylaxis was

indicated but not given

• Death of a patient after an inpatient fall



• Maternal death

• Intra-partum stillbirth or unexpected early neonatal death (0-7 days)

• Patient suicide whilst under the care of the mental health services

• Death or serious injury to other whilst under the care of mental health

services

• Missed diagnoses of cancer or a life limiting condition

• Death or significant harm of a child of vulnerable adult due to physical

neglect or intentional harm

Environmental events that have caused death. Significant harm or required

intervention to save life

• Electrocution whilst receiving healthcare

• Inhalation of toxic substances - Including legionella

• Burns and scalds whilst receiving healthcare

Other events

• These are events that would be reported via the Datix system, is a

significant near miss or recurring theme that the senior clinical team in

conjunction with the associate Nurse or Medical Director agree warrant

review using SAER process. The rationale for review will be due to the

potential to cause significant harm or death. In these cases the event will

be escalated to the Nurse and Medical Director for decision making.

NHS Borders Yes we have a never event list this is currently being updated as part of the

process of updating our local policy, the draft version is attached.

Draft NHS Borders Unacceptable and Preventable Events List.doc

NHS D&G Events that should never happen




Unexpected Events related to care and treatment that have caused death,

significant harm or required intervention to save life


• Unexpected anaesthetic, intra-operative or immediate post –operative

death

• Medication Error – Wrong drug, wrong dose, wrong patient, wrong time,

wrong rate, wrong preparation or wrong route of administration

• Haemolytic reaction due to the administration of incompatible blood

• Unexpected significant hypo- or hyperglycaemia occurring in the

secondary healthcare environment

• Grade 3 and 4 pressure ulcers acquired in Hospital with no previous skin

problems

• Unexpected death from sepsis

• Venous thrombo-embolus acquired in hospital where prophylaxis was



indicated but not given

• Death of patient after an inpatient fall

• Maternal death

• Intra-partum stillbirth or unexpected early neonatal death (0-7 days)

• Patient suicide whilst under the care of the Mental Health services

• Missed diagnosis of cancer or a life-limiting condition

• Death of significant harm or a child or vulnerable adult due to physical

neglect or intentional harm

Environmental Events that have cause death, significant harm or required

intervention to save life

• Electrocution whilst receiving healthcare

• Inhalation of toxic substances – including Legionella

• Burns and scalds whilst receiving healthcare

Other Events

• These are significant adverse events that would be reported via the Datix

system, is a significant near miss or recurring theme that the Senior

Clinical Team, in conjunction with the Associate Nurse or Medical

Director, agree warrant using the Significant Adverse Event review

process. The rationale for review will be; the potential to cause

significant harm or death to patients and their families, staff, visitors or

the organisation (e.g. serious breach of information governance. In these

cases, the adverse event will be escalated the Executive Nurse and

Executive Medical Director for decision making.

Criminal events such as wilful administration of care process, treatment or

medications to cause harm, physical assault or sexual assault may require review

using the Significant Adverse Event Review process. These events will initially be

subject to review by Police.

NHS Fife 1a. No, we do not currently collect information on a list of ‘Never Events’.

1b. In our List of Distinct Events that must always be reported we include

examples of events that should never occur. e.g.





Several ‘Never Events’ could be reported against any one of a number of our

current Datix sub categories e.g.

• Wrong Site Surgery

• Retained Instrument Post Operation

• Misplaced Naso or Orogastric tube not detected prior to use

• Wrong Route Administration of Chemotherapy

• Escape from within the secure perimeter of medium to high secure

mental health services by patients who are transferred prisoners



• In hospital maternal death from post partum haemorrhage after elective

caesarean section

• Intravenous administration of mis-selected concentrated potassium

chloride

• In patient suicide using non-collapsible rails

NHS Forth Valley Not currently but can pull information using some of the Safeguard reports:

We currently list all never events that MUST be reported and are working on a

process that would make collating information easier. We could do this now but

it would be a manual search. See list at end of report.

NHS GG&C Yes – from a modified NPSA date set; see attached below.

ASM

NHS Grampian We are not currently planning incorporating never events into our process. A

high degree of focus currently exists around the category I incidents given that

never events would most likely be category I where would the benefit be of

grouping just them? Would there be a tendency to focus on never events rather

than themed learning?

NHS Highland No.

NHS Lothian No. We are currently considering merit of building a flag into Datix to enable

identification in line with NPSA core list (8, which are evidence based), very

small numbers however.

NHS Tayside - Wrong Site Surgery

- Retained Instrument Post Operation

- Misplaced Naso or Orogastric tube not detected prior to use.

- Wrong Route Administration of Chemotherapy

- Escape from within the secure perimeter or a medium or high secure

mental health service by transferred prisoner.

- In Hospital Maternal Death from Post Partum Haemorrhage after

Caesarean Section

- Intravenous administration of mis-selected concentrated potassium

choloride

- Impatient suicide using non-collapsible rails.

NHS WI Yes. NPSA list.

Microsoft Office Word 97 - 2003 Document

NHS24 No, however, any death within 24 hours of contacting the service is investigated

Would like to develop a list applicable to NHS24

NWTC Although we do not formally collect never events this is a good idea and we are

currently looking to incorporate it into our update IR policy.

SAS Yes, we’ve adapted the NPSA list to be appropriate for the Ambulance Service.



State Hospital N/A


• 8 use a “never-events” list, or similar. Of these:

- 6 have adapted the NPSA list

- 2 use the NPSA list

• 7 do not use a “never-events” list, or similar. Of these:

- 3 are considering the use of the list

2. How are your ‘never events’ collected / coded e.g. on Datix or another

system?

NHS A&A Datix system.

NHS Borders The unacceptable and preventable events can be collected in a number of ways

depending on which event you require.

• Information can be collected via type of adverse event and sub

categories

• Information can be collected through specialised sections of forms (e.g.

medication event, equipment, RIDDOR)

All information can be accessed via the design a report function in Datix.

Each type of these events can be reported on the current system. These are

coded in the same way as all other types of adverse events recorded on the

system. The code details are specific to NHS Borders.

NHS D&G Never events are collected on Datix. Our never events form part of our

Significant Adverse Event process and are triggered at Categories G, H and I

(level 1)

NHS Fife While not categorised as ‘never events,’ all adverse events are captured in Datix.

NHS Forth Valley They are recorded through the normal process. See list at end of report.

NHS GG&C Collected in Datix.

NHS Grampian N/A

NHS Highland N/A

NHS Lothian N/A

NHS Tayside Above list is within Datix as sub categories.

NHS WI Never Events are coded on to our Datix System.

NHS24 Internal “respond” system.

NWTC We would use Datix.

SAS They are not coded on Datix, we tend to use them when confirming if an

incident is a SAE or not.

State Hospital N/A

Analysis All those who use a “never-events” list, or similar, would be collected on Datix

(or other incident management system).

3.

3a.

Do you call these ‘never events’ or another name?

Would an alternative name be preferable?

NHS A&A See response to question 1.

NHS Borders An alternative name is preferable as the list we work to are more than national

ever events, we have named the list in our newly revised policy as ‘NHS Borders

Unacceptable and Preventable Events’



NHS D&G We use never events.

NHS Fife See above

NHS Forth Valley We suggest that Never Events must be reported, there is no discretion at to

doing so or not, and it is an absolute. Apart from that they are reported

normally but would be managed as a Significant Adverse Event.

NHS GG&C Avoidable Serious Events Monitoring (ASEM)

NHS Grampian N/A

NHS Highland Some of these are defined in our incident management policy and procedure as

significant events.

NHS Lothian Sentinel events, however, essential to ensure common understanding.

NHS Tayside Never Events, and alternative could be considered.

NHS WI They are coded as Never Events and training is provided as part of overall Risk

Management Training.

Staff are now becoming familiar with the term so an alternative name will not

be preferable for us.

NHS24 No.

NWTC ‘Never events’ does what it say on the tin! I like it.

SAS We call them never events.

State Hospital N/A


• 5 use “never-event”

• 1 uses “events that are to be escalated”

• 1 uses “unacceptable and preventable events”

• 1 uses “avoidable serious events monitoring (ASEM)”

• 1 uses “sentinel events”

2 NHS boards expressed that they would not like the term amended:

• Staff are familiar with the term

• Descriptive of meaning

4. What do you use the information for i.e. are reports formed and who receives

them?

NHS A&A The events are linked with a consequence grade and escalated to the Associate

Medical Director and Associate Nurse Director. They will initiate a brief review;

provide an SBAR report for consideration by the Medical Director or Nurse

Director. This will result in either a full significant adverse event review being

called or a directorate review. Thereafter, the reports /findings etc are cascaded

through the identified governance routes.

NHS Borders There is not a specific report on never events but they would be reported within

the overall reporting for adverse events.

NHS D&G Reports are submitted to and considered by our Quality and Patient Safety

Leadership group and where appropriate they may commission a Significant

Review Investigation. Annual Report on ‘Never Events’ to HCG Committee.

NHS Fife Specific reports are not currently created. Such events would be subject to SAER

They would be reported to Governance Groups and Committees as part of

existing reports.

NHS Forth Valley Reports on ‘never events’ are currently not run as they are created on the

current Adverse Events process and sent to the Units. These reports vary in



layout, content and detail and are designed to suit the need of the requestor or

Unit. We are looking into providing an ability to generate a ‘Never Event’ report

automatically.

NHS GG&C The Board receive a regular report which denotes trends, types, and outcomes;

Acute Clinical Governance Committee & Board Quality & Performance

Committee.

NHS Grampian N/A

NHS Highland N/A

NHS Lothian N/A

NHS Tayside Report on these as part of a midyear and yearend report to the Audit

Committee who has delegated responsibility for risk management from the

Board. Also when these are reported within the system they are graded as red

and automatic notification is sent to members of the executive team. These are

also considered for Significant Clinical Event Analysis.

NHS WI Any Never Events reported will be included in our quarterly incident report

which is disseminated to Management Teams, Clinical Governance Groups and

Healthcare Governance Committee.

NHS24 Reports, presentations through clinical governance structure.

NWTC N/A

SAS We use them for identifying if an incident should receive a SAE Review.

State Hospital N/A

Analysis • Escalated to AMD/AND, prepare SBAR for consideration by MD/ND to decide

whether to call a full SAER

• Included in quarterly incident management reports.

• Mid-year and year-end reports to audit committee. When report they are

graded red and the executive team are automatically notified

• Normal SAER process

• Reports considered by quality and patient safety leadership group, a SAER

may be commissioned if appropriate. An annual “never events” report is

submitted to the healthcare governance committee.

“never- events” were reported to generally be reported and dealt with in a

similar way to other adverse events.

5. Have you found any benefit from collecting these events?

NHS A&A This has introduced a standardised process but we have also identified that too

many events are being flagged wherein the attempt was to narrow down to the

most serious. Part of this is an educational problem for staff completing the

Datix. However, there is over 10,000 staff so training takes time.

NHS Borders Perhaps through time this will be useful to monitor numbers and if local

proactive patient safety workstreams are achieving the desired outcomes of

reducing these types of events.

NHS D&G The information in the events is important for learning to prevent reoccurrence

NHS Fife N/A

NHS Forth Valley N/A

NHS GG&C Definitely. Focuses the minds on the occurrence of events which are avoidable

and as such act as a good balancing measure for Boards safety performance.



Provides the ability to assess if improvements implemented have made a

significant difference.

NHS Grampian N/A

NHS Highland N/A

NHS Lothian N/A

NHS Tayside Yes. Able to track data over time and make systems improvements from

incident reviews.

NHS WI We have only had 1 reported in the last 5 years so difficult for me to comment.

NHS24 Clear intelligence and data.

NWTC N/A

SAS Yes, in identifying if SAER.

State Hospital N/A

Analysis All NHS boards who reported collecting this information noted that they found

this useful. Other comments were also recorded:

• Acts as a good balancing measure for NHS board’s safety performance

• Allows the ability to assess whether improvements have made a significant

difference

• Focuses the mind on incidents which can be prevented

• Important to prevent reoccurrence

• Too many events are being flagged up – training issue but will take time

6. Any other comments?

NHS A&A N/A

NHS Borders Unsure of how this information is to be utilised for the future.

NHS D&G N/A

NHS Fife N/A

NHS Forth Valley The critical thing is to ensure that we have a robust for sharing the learning and findings

from the high end events. How we get to that has in the main been laid out in the HIS

review. The critical thing now is to identify what we need to share and agree a vehicle

to do so.

NHS GG&C N/A

NHS Grampian Do we have a clear understanding of how the benefits experienced in England with the

introduction of never events?

NHS Highland N/A

NHS Lothian N/A

NHS Tayside N/A

NHS WI No.

NHS24 A working group to develop a never event list for Scotland would be useful. Previously

had one set up at SG by a PhD student.

NWTC N/A

SAS N/A

State N/A

Analysis • The critical thing is to ensure that we have a robust for sharing the learning and

findings from the high end events. How we get to that has in the main been laid out

in the HIS review. The critical thing now is to identify what we need to share and

agree a vehicle to do so.

• Do we have a clear understanding of how the benefits experienced in England with

the introduction of never events?



• A working group to develop a never event list for Scotland would be useful.

Previously had one set up at SG by a PhD student.

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