The Management of Significant Adverse Events in NHS

More documents

Recommendations

Info

The Management of Significant Adverse Events in NHS Ayrshire & Arran – June 2012CONCLUSIONS AND RECOMMENDATIONS FORNHS AYRSHIRE & ARRANNHS Ayrshire & Arran has sought to build a more open and transparent approach to themanagement of significant adverse events and has made progress in this regard. It hassought to actively involve families in this exercise.However, and notwithstanding the considerable efforts made to build an improvedsystem, the Review Group identified material weaknesses in the system of significantadverse events review management. Many of these related to document control andsystems of governance. However, the Review Group felt that the more substantialshortfalls related to staff involvement, action planning and the dissemination of widerlearning. In summary, the Adverse Event Policy and Supporting Procedures was notreliably or consistently applied in NHS Ayrshire & Arran.The following recommendations are made.Recommendation 1:NHS Ayrshire & Arran should work, building on AthenA, to establish a single robustdatabase of significant adverse events that allows easier tracking of progress and averifiable audit trail.Recommendation 2:NHS Ayrshire & Arran should ensure that whatever system is used, there is clarity ofrecording of complete and consistent information with appropriate connectivity andaudit trails between systems.Recommendation 3:NHS Ayrshire & Arran should ensure that there is an appropriate level of scrutiny of theinformation in the Datix system to give assurance to the Board as to the robustness ofthe identification, management and learning from significant adverse events.Recommendation 4:NHS Ayrshire & Arran should establish a robust and transparent process for theescalation of adverse events, and ensure decisions therein are well documented.Recommendation 5:NHS Ayrshire & Arran should undertake a retrospective analysis of the deaths that didnot proceed to significant adverse event review, to provide assurance that appropriateinvestigation and learning was undertaken.Recommendation 6:NHS Ayrshire & Arran should move to a consistent model for significant adverse eventreviews, ensuring the effective involvement of a multidisciplinary team.6
The Management of Significant Adverse Events in NHS Ayrshire & Arran – June 2012Recommendation 7:NHS Ayrshire & Arran should review the timeline performance targets, ensuring thatthey are ambitious, but achievable. NHS Ayrshire & Arran should ensure a transparentapproach to reporting on progress against such targets with early intervention, toimprove performance, as appropriate.Recommendation 8:NHS Ayrshire & Arran should build on its approach to involving families in thecommitment to ensure greater openness.Recommendation 9:NHS Ayrshire & Arran should establish a robust system for tracking and responding tothe issues raised by families. This system should be integral to the overall system for themanagement of significant adverse events.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.Recommendation 11:NHS Ayrshire & Arran should build on its approach to the support of staff involved insignificant adverse events.Recommendation 12:NHS Ayrshire & Arran should make urgent progress in establishing the status of allsignificant adverse event review action plans since 2009. NHS Ayrshire & Arran shouldalso consider the scope to extend their review to cases pre-dating 2009, within thebounds of the information that is available.Recommendation 13:NHS Ayrshire & Arran should ensure an ongoing approach to thematic learning, givingopportunities for those working in NHS Ayrshire & Arran to learn from significantadverse events and to change and adapt clinical practice accordingly.Recommendation 14:NHS Ayrshire & Arran should review its clinical governance structure with the focus ondelivering a more streamlined and simpler arrangement, giving sharper clarityregarding accountability.Recommendation 15:NHS Ayrshire & Arran should ensure a focus on empowering clinical services todevelop, own and progress action plans and to share wider learning and to reflect this ina revised flowchart.Recommendation 16:NHS Ayrshire & Arran should ensure that Healthcare Directors have explicit objectivesrelated to the effective organisation and learning from significant adverse events, andsuch objectives are cascaded, appropriately, through their Directorates.7
Page 2 and 3: The Management of Significant Adver
Page 46: www.healthcareimprovementscotland.o

The Management of Significant Adverse Events in NHS

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?