The Management of Significant Adverse Events in NHS

The Management of Significant Adverse Events in NHS Ayrshire & Arran – June 201272 The model, adopted in NHS Ayrshire & Arran, of an independent scrutiny team tolead significant adverse event reviews, excludes staff directly involved in the incidentsand runs the risk of failing to obtain ownership of the action plans and improvements.Operational staff also felt, in some instances, that they had important insight andknowledge that could have been shared and used throughout the process, but theprocess did not allow their voice to be heard.73 The Review Group concluded that the general approach to the managementof significant adverse event reviews did not encourage an appropriate level ofengagement with staff, particularly those directly involved in the incidents, with aresultant impact on the ownership of the findings, implementation of action plansand ultimately learning.Recommendation 10:NHS Ayrshire & Arran should review its approach to the involvement of staff in theinvestigation of significant adverse events, with the aim of offering consistentopportunities for learning and improvement.74 The Review Group did hear positive feedback regarding the contribution of theCritical Incident Stress Management resource. It was viewed as being very supportive ofstaff and offered a “structured system of care” as set out in paragraph 5.3 of the AdverseEvent Policy and Supporting Procedures. NHS Ayrshire & Arran should seek to sustainand develop this.Recommendation 11:NHS Ayrshire & Arran should build on its approach to the support of staff involved insignificant adverse events.3.7 Action Planning75 During the time period studied by the Review Group, the Clinical GovernanceCommittee received full Significant Adverse Event Review Reports and associatedaction plans and discussed them at their meetings. The minutes recorded varying levelsof detail in respect of the consideration of the Significant Adverse Event ReviewReports.76 The Clinical Governance Annual Report for 2010/11 notes in paragraph 8 that:“Eighteen significant adverse events were reported to the Committee. These took the formof an independent review of the incident, identifying contributory factors and a set ofconclusions and recommendations. These reports were discussed in detail by the ClinicalGovernance Committee and were then reviewed (or plan to be reviewed), typically after 6months to check on progress. A review of all cases was done to identify causal trends andactions undertaken.”77 The PwC report commented that:26