Learning from errors

Through high-quality patient safety monitoring, organisations can use their own patient safety data to drive improvement. Incident reports can be obtained from local incident reporting systems. These can then be used to compare with similar trusts using the NRLS or NHS Improvement data on patient safety alert compliance and never events.

For more information on how to use data to improve services please see the section on quality improvement and accessing data.

Organisations can also sign up to NHS England’s Sign up to Safety Campaign. This campaign aims to help member organisations listen, learn and take action to ensure patients receive harm-free care. It provides Safety Improvement Plan guidance (opens PDF) webinars on improving organisational safety, as well as sign-posts to a variety of online resources on patient safety.

Managing incidents

All organisations should have robust systems in place to deal with incidents and healthcare crises. Although they are rare, serious incidents and never events do occur and if not dealt with effectively, can have significant impact on patients and staff.  Root cause analysis (RCA) is an established way of investigating and analysing these incidents in order to identify areas for change and improvement. The RCA resource centre has been developed to support widespread good practice. It provides:

  • tools to help with investigations
  • templates to record investigation findings
  • guidance on carrying out investigations
  • an e-toolkit with a framework for investigation.

Patient safety investigation should also take into account the Serious Incident Framework which ‘outlines the process for conducting investigations into serious incidents in the NHS for the purposes of learning to prevent recurrence’. It supports the use of seven key principles in the management of all serious incidents:

  • open and transparent
  • preventive
  • objective
  • timely and responsive
  • systems-based
  • proportionate
  • collaborative.

Learning from national reviews

Many previous reviews of patient safety such as the Keogh Review, the Berwick Review, the Mid Staffordshire NHS Foundation Trust Public Enquiry and the Bristol Royal Infirmary Inquiry have highlighted very similar themes. It is outside the scope of this resource to provide detailed summaries of all these reports. However, it is important that all service mangers and clinical leads ensure that they have robust systems in place to encourage the following:

  • leadership and accountability this includes leading teams, ensuring safe staffing, ensuring there is an accountable named clinician for each patient and ensuring that junior staff are supported
  • robust governance systems  this includes ensuring there are systems in place to deal with incidents. This includes governance structures, reporting systems, feedback to staff and families when things go wrong, adequate handover of patients and access to higher levels of care when required
  • communication – ensuring good communication between all members of the multidisciplinary team, allowing staff to raise concerns without fear of punitive action and improving communication from the ward to the board
  • listening to patients and service users – a key criticism levied in the Francis report was the failure to listen to patients and their loved ones, ensure service users have a voice and are able to speak up freely formally and informally and gather regular patient feedback
  • culture of learning – encouraging all staff to report near misses, low harm events and patient safety incidents without fear fosters a culture of learning.

Other national initiatives on patient safety include the work done by NCEPOD, for example their recent reports on time critical issues such as sepsis management and GI haemorrhage. The NCEPOD reports contain recommendations for all organisations to integrate into their processes of care. For instance, in the case of sepsis, particular attention should be paid to ensuring early senior review, availability of sepsis screening bundles, and access to higher levels of care.