The Management of Significant Adverse Events in NHS

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The Management of Significant Adverse Events in NHS Ayrshire & Arran – June 2012114 In the view of the Review Group, the approach taken by NHS Ayrshire &Arran hampered the delivery of the primary objectives of the Adverse Event Policyand Supporting Procedures to learn from significant adverse events and topromote wider learning and improvement.Recommendation 17:NHS Ayrshire & Arran should undertake a fundamental review of its approach tosharing information arising from significant adverse events. It should ensure that theapproach remains within the legislative requirements, but maximises the opportunitiesfor staff to understand the broader context and background regarding specific incidents.34
The Management of Significant Adverse Events in NHS Ayrshire & Arran – June 2012APPENDIX 1: TERMS OF REFERENCEHealthcare Improvement Scotland: Review of NHS Ayrshire & Arran SignificantAdverse Event Systems and ProcessesFocus on the Management of Critical Incidents/Adverse Events, Action Planningand LearningMarch 2012BackgroundConcerns have been raised about the NHS Ayrshire & Arran’s arrangement formanaging, reviewing and acting on critical incidents and adverse events. The CabinetSecretary for Health, Wellbeing and Cities Strategies has now formally asked HealthcareImprovement Scotland to undertake an urgent review of the clinical governancesystems and processes in NHS Ayrshire & Arran, in particular those that relate to theirmanagement of critical incidents, adverse events, action planning and local learning.Healthcare Improvement Scotland has carried out a number of similar reviews and thefocus is on ‘diagnosing’ the key issues and supporting the relevant NHS board(s) indeveloping and implementing improvement plans. More generally, the focus is onshared learning across the NHS in Scotland and healthcare providers generally.The specific request for the review has arisen following a report by the ScottishInformation Commissioner (Decision 036/2012) – Mr Rab Wilson and NHS Ayrshire &Arran.The Scottish Information Commissioner investigation and a recent (November 2011)NHS Ayrshire & Arran Internal Audit report from PricewaterhouseCoopers (PwC) –Significant Adverse Events Review – highlighted a number of governance issues inrelation to the effectiveness of the clinical incident review/significant adverse eventprocess within NHS Ayrshire & Arran between 2006 and 2011.Remit and scope of reviewHealthcare Improvement Scotland will review and report on NHS Ayrshire & Arran’ssignificant adverse event policy and supporting procedures. The aim is to ensure thereis systematic, comprehensive and transparent approach to management and follow-upof significant adverse events. The review will ensure that the approach maximises theopportunities for learning, and explicit action for service change and improvement isembedded throughout the organisation. Learning opportunities will also be sharedmore widely across all healthcare providers.The Healthcare Improvement Scotland review will focus on the:• systems related to the identification, investigation, reporting, documentation andlearning from significant adverse events in NHS Ayrshire & Arran• relationship between clinical governance support and operational (includingmanagement and human resources/clinical services in the management ofsignificant adverse events, and35
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The Management of Significant Adverse Events in NHS

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