The Management of Significant Adverse Events in NHS

The Management of Significant Adverse Events in NHS Ayrshire & Arran – June 2012• opportunities for the wider improvement of the management of significantadverse events in NHSScotland and healthcare providers in general with aparticular emphasis on openness, transparency and shared learning.Proposed methodThe review will be undertaken using a group made up of individuals with specialistknowledge from across NHSScotland, including the Director of Scrutiny & Assurance atHealthcare Improvement Scotland, and will include the following methods.• Review of NHS Ayrshire & Arran’s serious adverse events policy, procedures andrelated documentation in the context of their clinical governance and riskmanagement arrangements.• Draw from/ensure, appropriate linkages with recent related HealthcareImprovement Scotland clinical governance and assurance work.• Review of information systems to support the management of significant adverseevents within NHS Ayrshire & Arran.• Interviews with key staff to ascertain typical process adherence andunderstanding throughout the organisation. This will take account of the viewsof operational staff at the frontline, the Executive Team, clinical governance andany other involved staff. A number of key controls will be tested and cover, in thefirst instance, the following:- a consistent and robust approach to reviewing and updating theorganisational understanding, compliance and capability of the systemsand process associated with significant adverse events, specifically:- identification of significant adverse events- assessment of significant adverse events, including consistent triggers- reporting (including document storage and consistency) and escalation ofserious adverse events- key roles and responsibilities following a significant adverse event,including organisational relationships and partnerships across theorganisation- associated training and staff capability- key learning, sharing, improvement and action planning, and- staff engagement and follow-up to reporting.The review will be completed with the presentation of a report with associated riskasedrecommendations and may include any appropriate Learning and ImprovementBriefings. This report will be sent to the Scottish Government Health & Social CareDirectorates on completion.36