The Management of Significant Adverse Events in NHS

The Management of Significant Adverse Events in NHS Ayrshire & Arran – June 2012EXECUTIVE SUMMARYThe Cabinet Secretary for Health, Wellbeing and Cities Strategy instructed HealthcareImprovement Scotland to carry out, as a matter of urgency, a review of the clinicalgovernance systems and processes in NHS Ayrshire & Arran, in particular those thatrelate to their management of critical incidents, adverse events, action planning andlocal learning.This followed a decision by the Scottish Information Commissioner on 21 February2012 on NHS Ayrshire & Arran’s response to a Freedom of Information (Scotland) Actappeal regarding critical incident reviews and significant adverse event reviews.This document reports on the findings of the Healthcare Improvement Scotland ReviewGroup and makes recommendations for improvement for both NHS Ayrshire & Arranand NHSScotland.The key findings from the report are summarised below.• The Review Group found a lack of clarity on the lines of accountability, reportingand ownership of significant adverse event review actions and learning. Wefound complex and unwieldy clinical governance structures (see section‘Structure and Accountability’).• The Review Group found confusion about staff understanding of the scope toshare information on significant adverse event reviews and a variation ininterpretation of the policy. This hampered learning and improvement (seesection ‘Sharing of Information’).• Although the Review Group found examples of comprehensive SignificantAdverse Event Review Reports there was not a robust and systematic approachto implementing action plans and monitoring progress (see section ‘ActionPlanning’).• The Review Group found that NHS Ayrshire & Arran had a commitment toinvolve patients and families and raise awareness of the need to involve families.The system that tracks and responds to issues raised by families was an area ofweakness and the Review Group found an inconsistent approach was used tofamily involvement (see section ‘Involvement of Families’).• The Review Group did not find evidence of a system to identify thematic learningto allow change and improvements to clinical practice (see section ‘Sharing oflearning’).• There is strength in the potential of AthenA (NHS Ayrshire & Arran’s electronicdocument management system) to support the management of significantadverse events. However, the Review Group found weaknesses in: the loggingand monitoring of significant adverse events; how NHS Ayrshire & Arranconnects the information systems it uses; and the level of scrutiny applied to the4