Learning from adverse health care events in Scotland

By John Tingle

We can learn a lot from how other countries deal with patient safety issues and it can save us from reinventing the wheel at some financial cost.Healthcare improvement Scotland  (HIS) is the national healthcare improvement organization for Scotland and is part of NHS Scotland. The organization provides some excellent patient safety resources. The work of HIS involves supporting and empowering people to have an informed voice in managing their own care and shaping how services are designed and delivered. Delivering scrutiny activity, providing quality improvement support and providing clinical standards, guidelines and advice. HIS produce a rich range of programmes and publications that are relevant to all those concerned with patient safety and health quality in England, USA and elsewhere.

A recent report from HIS focuses on the adverse event lessons learned by health boards and the improvements they subsequently put into place after the events,Learning from adverse events – Learning and improvement summary: May 2016 There is some very good thinking in the report which should be essential reading for all staff involved in patient safety policy development.

The report begins by making the point that it is internationally recognized that between 10%–25% of episodes of healthcare (in general hospital, community hospital and general practice) are associated with an adverse event. The report emphases the need to have effective processes in place to properly manage adverse events.  Also that lessons are learnt from the adverse events which can then inform positive changes and lead to improvements. The areas of good practice found are:

  • Sharing learning
  • Patient, family or carer engagement
  • Staff engagement and support
  • Tools, guidance and processes
  • Governance and overview
  • Quality improvement

On sharing learning and the lessons learned  a good and wide range of communication mechanisms were revealed in some parts of the NHS in Scotland which included:

NHS 24 supports individual learning by reviewing the effectiveness of communication mechanisms, such as safety huddles, ‘hot topics’, e-learning, managerial feedback to staff and the visibility of staff noticeboards.

NHS Borders nursing staff are required to bring examples of patient feedback and relevant complaints or adverse events to their appraisal sessions, to support individual reflection and learning, and identify any development needs.”

On patient family, or carer engagement some good practice identified included

NHS Forth Valley generally invites the patient, family or carer to take part in the adverse event review process at an early stage, so that any concerns can be identified and addressed promptly.”

In NHS Grampian, it is now mandatory for staff to offer the patient, family or carer the opportunity to become involved in the review process for all category 1 reviews (adverse events that may have contributed to or resulted in permanent harm). Feedback advisors also attend feedback meetings with the patient, family or carer, by phone or face to face, to encourage early resolution, and to ask them “What is it you want from the process.

All together a first class report which shows some very useful patient safety initiatives taking place in Scotland. The report is an excellent learning tool containing some very useful case studies.

John Tingle

John Tingle is a regular contributor to the Bill of Health blog. I am a Lecturer in Law, Birmingham Law School, University of Birmingham, UK; and a Visiting Professor of Law, Loyola University Chicago, School of Law. I was a Visiting Scholar at Harvard Law School in November 2018 and formerly Associate Professor at Nottingham Law School, Nottingham Trent University in the UK. I have a fortnightly magazine column in the British Journal of Nursing where I focus on patient safety and the legal aspects of nursing and medicine. I have published over 500 articles and a number of leading texts in patient safety and nursing law. My current research interests are in global patient safety, policy and practice, particularly in African health care systems. My most recent publication is: "Global Patient-Safety Law Policy and Practice," edited by John Tingle, Clayton O'Neill, and Morgan Shimwell, Routledge 2018.

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