A national approach to learning from adverse events through reporting, review and the sharing of learning

An adverse event can be defined as an event that could have caused, or did result in, harm to people or groups of people.

Following a detailed review of NHS Ayrshire & Arran’s adverse event management in the spring of 2012, the Cabinet Secretary for Health, Wellbeing and Cities Strategy instructed Healthcare Improvement Scotland to develop a national framework and a programme of reviews. Between autumn 2012 and spring 2014, we visited every patient-facing NHS board to review their processes for managing adverse events.  In September 2013, we published a National Framework for managing adverse events following extensive consultation. The framework supports NHS boards to standardise processes. It includes a national definition of an adverse event, guidance on reporting, accountability, responsibilities and learning, and principles for an open, just and positive safety culture. In April 2015, we published a refresh of the National Framework.

 This programme of work:

  • supports a consistent national approach to identification, review, reporting and learning from adverse events based upon national and international good practice
  • promotes the sharing of learning points following adverse event reviews through our Community of Practice site, regular network meetings and the publication of an annual Learning and Improvement report featuring good practice and improvement examples (see below), and
  • provides public assurance on the appropriate management of adverse events through progress meetings with NHS boards and engagement with NHS representatives through our adverse events network and short-life working groups.

Our resources

Scrutiny

Learning and improvement report

Read our learning and improvement report for detailed information on our work to help improve adverse events management across NHS Scotland.

Management of adverse events review visits

Frequently Asked Questions

Find out more about about the focus, purpose and procedure of our review visits to NHS boards.

For more information or if you have any further questions, please email the adverse events team at:

hcis.adverseevents@nhs.net 

 

Community of practice site

Key learning points following adverse event reviews are being shared widely on our adverse events Community of practice site.