Talk Health and Care

Learning from serious incidents

As with the Duty of Candour, we have a responsibility to be open and honest with our patients and communities when something hasn't gone right and potential or actual harm is caused. However, should this responsibility be extended to be open and honest with ALL employees of that NHS Trust? Bear with me..


I know that many Trusts will publish their serious incidents internally to assist with staff training and learning. But should this not be a mandatory action to create a just learning environment and culture? 


I propose that Trusts report monthly regarding serious incidents as well as 'near misses' in an internal newsletter (or similar) distributed to ALL staff. This way, all staff members of that Trust are able to learn from errors, thus creating an open and honest culture. One which encourages open and honest reporting of system errors as well as human factor errors. Perhaps this could also incoporate a 'Greatix' reporting mechanism, for reporting everything that is good in an organisation. 


The unintended concequences to be aware of are potential sharing of patient identifiable details without express consent, and potentially sharing of incidents that may encourage changes in behaviour that could be seen as 'outside' of policy / scope of practice. There may be more that I haven't captured, but hopefully this is the beginning of something positive.. And I'm sure technology could have a huge part in this. 

edited on Nov 2, 2018 by Isabel DHSC

Golly DHSC 10 months ago

Hi Kieran,

Thanks for taking the time to share your ideas. Do have any examples where you've seen this done well? It would be great to capture some best practice in this area.


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Kieran Potts 10 months ago

I think East of England Ambulance Service have a bulletin released regarding incident learning - it certainly is being done in one amb Trust. I've heard some use of 'Greatix' too, but I'm not sure where it is in use.

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Kayak 9 months ago

Kieran, I absolutely agree. Golly DHSC If you want examples of where this has been done well, look no further than aviation - military and civilian. During my time in aviation sharing near misses was as important as sharing the incidents. If not more so, why wait for something to go seriously wrong before you learn from it. What it does need is a change in culture (from regulatory bodies downwards) so that people can report safely. As an example if after-action reviews / de-briefs become the norm, instead of only after SI's, then considerable learning would take place.

Additionally if there was an anonymous channel for sharing near misses, that could reduce the risk people may feel to owning up to issues. There are anonymous systems in aviation.

People are human, humans make mistakes so lets really think about the human factors here. If we work on the premise that most people come to work to do the best job that they can, then we can put in place the support for people to do that. Instead of punitively auditing people to destruction.

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