The Management of Significant Adverse Events in NHS

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The Management of Significant Adverse Events in NHS Ayrshire & Arran – June 2012© Healthcare Improvement Scotland 2012First published June 2012The publication is copyright to Healthcare Improvement Scotland. All or part of this publication may bereproduced, free of charge in any format or medium provided it is not for commercial gain. The textmay not be changed and must be acknowledged as Healthcare Improvement Scotland copyright withthe document’s date and title specified.www.healthcareimprovementscotland.org2
The Management of Significant Adverse Events in NHS Ayrshire & Arran – June 2012CONTENTSEXECUTIVE SUMMARY ......................................................................................................................... 4CONCLUSIONS AND RECOMMENDATIONS FOR NHS AYRSHIRE & ARRAN ......................... 6OPPORTUNITIES FOR LEARNING IN NHSSCOTLAND ................................................................ 91 INTRODUCTION ............................................................................................................................ 111.1 Background ......................................................................................................................................... 111.2 Methodology for the Review ........................................................................................................ 112 NHS AYRSHIRE & ARRAN’S DESCRIPTION OF ARRANGEMENTS ................................. 133 REVIEW FINDINGS AND RECOMMENDATIONS .................................................................. 163.1 Identification, Notification and Initial Event Reporting .................................................... 163.2 Escalation of Events ......................................................................................................................... 183.3 Types of Significant Adverse Event Reviews ......................................................................... 203.4 Investigation and Reporting Timelines.................................................................................... 223.5 Involvement of Families ................................................................................................................. 243.6 Staff Involvement.............................................................................................................................. 253.7 Action Planning ................................................................................................................................. 263.8 Sharing of Learning .......................................................................................................................... 293.9 Structure and Accountability ....................................................................................................... 303.10 Sharing of Information ................................................................................................................... 32APPENDIX 1: TERMS OF REFERENCE ............................................................................................ 35APPENDIX 2: EVENTS LEADING TO THE REVIEW ..................................................................... 39APPENDIX 3: LIST OF ADVERSE EVENTS ON NHS AYRSHIRE & ARRAN SIGNIFICANTADVERSE EVENT REVIEW DATABASE .......................................................................................... 413
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The Management of Significant Adverse Events in NHS

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