The Management of Significant Adverse Events in NHS

The Management of Significant Adverse Events in NHS Ayrshire & Arran – June 2012care and safety and reduce risk. This is the process now referred to as the SignificantAdverse Event Review.Indeed, a recent independent audit report by Price Waterhouse Cooper, while critical ofthe former process, finds little fault with the new SAER process for investigating adverseevents and publicising the learning points from them.”A further statement on the same day said that:“Prior to the introduction of the Significant Adverse Review Process (SAER) in 2009 theBoard did not have an established system for capturing actions taken as a result of reportsinto critical incidents. This meant the Board could not ensure and report that all necessarychanges to practice, identified from reports, were implemented. The Commissioner wasrightfully very critical of this and the Board accepts these comments, which relate to theperiod before 2009.Since the introduction of SAERs the necessary audit trails and assurance systems havebeen in place. This has been confirmed to the Board by both an external PwC audit that itcommissioned in 2011, and now also by the Commissioner’s findings.”The review by Healthcare Improvement Scotland has sought to give external scrutinyand assurance to the process of the management of significant adverse events in NHSAyrshire & Arran.40