Download Management of Significant Adverse Events and Reviews Supporting

Leaflet reference: MIS12-300-CC Review date: January 2014
Management of Significant Adverse
Events and Reviews
Supporting guidance and resources
Version 2, June 2013
All our publications are available in other formats
Visit our website www.nhsaaa.net
Leaflet reference: MIS12-300-CC Review date: January 2014
Foreword
In June 2012 Healthcare Improvement Scotland published their report into NHS Ayrshire & Arran’s
management of Significant Adverse Event Reviews (SAERs). In response, we developed an improvement
plan to address the issues raised by HIS’ review.
The improvement plan set out the actions we would take to ensure that, by 1 October 2012, NHS
Ayrshire & Arran would have in place an improved process for responding to and reviewing significant
adverse events. This process would enable:
• greater involvement of staff, patients and families;
• learning and improvement; and
• robust governance and reporting;
all supported by a business control system which would track every stage of a review.
This single publication introduced that new process. It contains all the guidance and resources you
might need if you are involved in any aspect of a significant adverse event review. It includes a step-bystep guide for conducting SAERs; sets out clearly the roles and responsibilities of those leading a review;
and spells out our commitments to staff, patients and families about what they can expect during a
review.
This publication is also available on our public website, www.nhsaaa.net, and is published on our staff
intranet, AthenA, as a suite of separate documents for the use of staff.
The content of this publication has been reviewed by staff involved in the reviews commissioned since
October 2012. The content has been revised as a result of feedback and learning. I am very grateful to
all staff who played a part in developing and further improving how we manage Significant Adverse
Event Reviews. I am delighted to endorse this second version of this guidance.
John G Burns
Chief Executive
June 2013
2.
Leaflet reference: MIS12-300-CC Review date: January 2014
Contents
Page
Significant Adverse Events to be reported4-5
SAER review process6-10
Commitments to patients and families involved in a Significant Adverse Event11
Our commitments to staff12-13
SAER process - roles and responsibilities14-18
Adverse event / near miss reporting and escalation process: immediate action guidance19-20
Checklist for immediate management actions following a Significant Adverse Event21-22
Checklist for decision making in commissioning a Significant Adverse Event Review23-25
Checklist for process of managing a Significant Adverse Event Review26-27
Checklist for implementing system analysis
28-29
Yorkshire Contributory Factors Framework (YCFF)
30-33
Guidance on disclosure of confidential information from Significant Adverse Event Reviews33-38
Evaluation of the Significant Adverse Event Review process
39
SAER staff evaluation questionnaire
40-41
SAER family evaluation questionnaire
42-43
SAER team evaluation questionnaire
44-45
Action Plan Guidance Document
46-56
SAER recommended reading and resources
57-59
3.
Leaflet reference: MIS12-300-CC Review date: January 2014
Significant Adverse Events to be reported
This list of Significant Adverse Events describes distinct events categorised by the organisation as ones
that must always be reported when they may have resulted in:
• unexpected death1;
• significant harm (harm includes negative physical and emotional impact) to a patient and family; and
• may have required intervention to save life.
These events must always be reported to the appropriate Associate Medical and Nurse Director who
will carry out initial review of the event, inform the relevant Director and refer the event to the Executive
Medical and Nurse Director for a decision whether to progress to Significant Adverse Event Review
(SAER). This must be actioned as soon as possible based on a brief review of the event. This initial review
is not an in-depth systems analysis. The AMD and AND may recommend a Directorate led system
analysis following this initial review . These events have been grouped into the following categories –
events that should never happen, unexpected events related to care and treatment and environmental
events. There may be other significant adverse events that, although not on this list, will still have ‘Major’
or ‘Extreme’ consequences and should to be reported through the Datix system.
Events that should never
happen
Surgery performed on the wrong body part
Surgery performed on the wrong patient
Wrong procedure performed on a patient
Unintended retention of a foreign object after surgery or a procedure
4.
1 Staff may be uncertain as to what constitutes unexpected death in relation to some conditions or clinical scenarios. If there is any doubt or
concern that not reporting may mean care system improvement opportunities would be missed, the death should be reported.
Leaflet reference: MIS12-300-CC Review date: January 2014
Unexpected events related
to care and treatment
that have caused death,
significant harm or required
intervention to save life
Unexpected anaesthetic, intra-operative or immediate post operative
death
Medication error – wrong drug, wrong dose, wrong patient, wrong
time, wrong rate, wrong preparation or wrong route of administration
Haemolytic reaction due to the administration of incompatible blood
Unexpected significant hypo or hyperglycaemia occurring in the
secondary healthcare environment
Grade 3 and 4 pressure ulcers acquired in hospital with no previous
skin problems
Unexpected death from sepsis
Venous thrombo–embolus acquired in hospital where prophylaxis
was indicated but not given
Death of patient after an inpatient fall
Maternal death
Intra-partum stillbirth or unexpected early neonatal death (0-7 days)
Patient suicide whilst under the care of the mental health services
Death or serious injury to others whilst under the care of mental
health services
Missed diagnosis of cancer or a life limiting condition.
Death or significant harm of a child or vulnerable adult due to
physical neglect or intentional harm
Environmental events
that have caused death,
significant harm or required
intervention to save life
Electrocution whilst receiving healthcare
Other events
These are events that would be reported via the Datix system, are a
significant near miss or recurring theme that the senior clinical team
in conjunction with the Associate Nurse or Medical Director agree
warrant review using the SAER process. The rationale for review will
be due to the potential to cause significant harm or death. In these
cases the event will be escalated to the Executive Nurse and Medical
Director for decision making.
Inhalation of toxic substances – including legionella
Burns and scalds whilst receiving healthcare
Criminal events such as wilful administration of care process, treatment or medications to cause harm,
physical assault or sexual assault may require review using the SAER process. These events will initially
be subject to review by police.
5.
Leaflet reference: MIS12-300-CC Review date: January 2014
SAER Process
Lead responsibility
Directorates
Lead responsibility
Executive Medical and Nurse
Directorates
Timeline
(Days)
Process
Descriptor
Refer to supporting
guidance
0
Significant Adverse
Event or a DATIX
event with a
consequence rating
of Major or Extreme
occurs
Make patient and
situation safe,
prevent further
harm
Inform Line Manager
and or Duty
Manager (if out of
hours) Consultant
and Senior Nurse
responsible for care
Line Manager or
Duty Manager to
inform Director (in
hours) or on call
Director (out of
hours)
Line Manager or
duty manager to
assess and address
staff support needs
Inform family
An event that has resulted in
unexpected death or significant harm
to a patient and family and may have
required intervention to save life.
Mandatory Distinct
Significant Adverse Events to
be reported
0
0
0
0
0
6.
All to document
what has happened
Lead responsibility
Shared Director and EMNDs
Datix Adverse Event/
Immediate Action Guidance
Checklist for Immediate
Management Actions
following a Significant
Adverse Event
Checklist for Immediate
Management Actions
following a Significant
Adverse Event
Checklist for Immediate
Management Actions
following a Significant
Adverse Event
Are staff psychologically safe
to continue to work or do they
require to be relieved of duties and
supported to get home?
Following discussion with the line
manager inform the family that
an event has occurred and extend
invitation to visit.
Checklist for Immediate
Management Actions
following a Significant
Adverse Event
Checklist for Immediate
Management Actions
following a Significant
Adverse Event
SAER Commitments to
Patients and Families
To capture what, how, who and when Checklist for Decision
of the event
Making in Commissioning
a Significant Adverse Event
Review
Leaflet reference: MIS12-300-CC Review date: January 2014
Timeline
within 3
working
days
Descriptor
Escalation will be followed by initial
Directorate review of event and
determine if reportable to END/
EMD. If this is the case an initial SBAR
(which need not be informed by
a comprehensive review process)
should be submitted on day 3.
1 working Line Manager / Duty CNM or CD responsible for
days
Manager will Inform submission of the SBAR to the
(WD)
the Associate Nurse appropriate AND AMD 1 working day
Director, Associate
Medical Director and
Executive Nurse /
Medical Director of
the occurrence of
the event and report
the event through
the Datix incident
reporting system.
2 WD
Process
Escalation to
Associate Medical
and Nurse Director
The Head of
Occupational Health
and Safety should be
advised.
AND/AMD to
conduct initial
review and will
provide the
Executive Medical
and Nurse Directors
with the original
Datix and SBAR
information, of
their assessment
of the event and
recommendations
regarding
progression or not
to full SAER review.
Where medication is
involved the advice
of the Director of
Pharmacy should
be sought and
included.
AND/AMD to review SBAR and use
professional judgement to make a
recommendation to the EMD and
END.
Refer to supporting
guidance
Checklist for Immediate
Management Actions
following a Significant
Adverse Event
Checklist for Immediate
Management Actions
following a Significant
Adverse Event
Checklist for Decision
Making in Commissioning
a Significant Adverse Event
Review
7.
Leaflet reference: MIS12-300-CC Review date: January 2014
Timeline
(Days)
1 WD
Process
Descriptor
Supporting Resources
END/EMD to make decision
regarding initiation of SAER process
or reasons why not. The decision
must be recorded and Directorate
management team concerned
informed.
Checklist for Decision
Making in Commissioning
a Significant Adverse Event
Review
1-3 WD
Decision whether
to progress to
SAER made and
communicated to
the Director and
AND, AMD. Inform
SAER Support
Co-ordinator (SSC)
SAER Initiated
Convene Leadership
Oversight Group
(LOG) to initiate the
SAER
Corporate AD responsible for
convening LOG. The LOG will focus
on family, staff and organisation
requirements and will agree the Lead
Reviewer, Technical Lead and the
family and staff contact person. The
LOG will not meet again until end of
process unless required due to the
need to undertake remedial action.
Arrange to meet
Corporate AD responsible for
with Family to agree conducting meeting with family in
expectations and
conjunction with the Lead Reviewer
contact
and family contact person.
Within 5
WD
Within 5
WD
Up to 45
WD
8.
Arrange to meet
with Staff to agree
expectations and
contact
Corporate AD responsible for
conducting meeting with Staff in
conjunction with the Lead Reviewer
and staff contact person.
Conduct SAER using Lead Reviewer will work with SAER
Systems Analysis
Technical Lead and identified subject
matter experts to conduct SAER
process. The whole process will be
overseen by the allocated Corporate
AD’s
SAER Roles and
Responsibilities
SAER Commitments to
Patients and Families
Checklist for Process of
Managing a Significant
Adverse Event Review
SAER Commitments to Staff
Checklist for Process of
Managing a Significant
Adverse Event Review
Guidance on Disclosure
of SAER Confidential
Information (including FAQs)
Checklist for Implementing
Systems Analysis. Please
refer to SAER Recommended
reading and resources
document.
Leaflet reference: MIS12-300-CC Review date: January 2014
Timeline
(Days)
Within 5
WD
Agreed
date
Process
Descriptor
Supporting Resources
All those involved
with SAER process
will be given
access to the SAER
electronic systems
to review and
monitor progress on
implementation. If
at any time during
the review process
there are concerns
that any issues
about conduct are
being identified,
the Lead Reviewer
will consult the
Corporate Assistant
Director who will
formally initiate a
pause to allow the
relevant operational
management and
HR colleagues to
discuss actions
necessary. This
pause will be no
longer than 48
hours.
Formal meeting
of LOG to receive
completed report
and consider
recommendations.
Corporate AD will be responsible for
monitoring progress.
SAER monitoring system
The LOG will receive details of the
SAER review process. It should also
receive confirmation that requests for
factual accuracy checks have been
actioned and that the SAER process
has been followed.
Formal approval by Formal approval will be generated
Executive Sponsor
following the LOG meeting
Findings and
Issue of report in line with
recommendations
information sharing guidance and
presented to families face to face meeting.
and staff
Checklist for Process of
Managing a Significant
Adverse Event Review
Report
9.
Leaflet reference: MIS12-300-CC Review date: January 2014
Within 10 Directorate is
WD
formally notified
of approval and
requirement for
development
of action plan
in response to
recommendations.
Through Review and
process
evaluation
of process
implementation
from all perspectives
Action plan developed in line with
organisational guidance.
Guidance document for
action plans
Formal evaluation of process, family
and staff experience.
SAER Staff Evaluation
Questionnaire
* Next
Directorate will present the
report and action plan to the next
Healthcare Governance Committee.
Directorate presents
to Healthcare
Healthcare
Governance
Governance
Committee
Committee
where assurance
requirements will be
agreed.
Ongoing Ongoing scrutiny
and assurance
to Board and/
or Healthcare
Governance
Committee
Quarterly Healthcare
Governance
Committee to
receive report on
evaluation of the
process and changes
that are required.
Quarterly Directors to receive
briefing on links
between Significant
Adverse Events
and other issues
to inform crossorganisational
learning and
Board Learning
and Improvement
Reports
10.
SAER Patient &/or Families
Questionnaire
SAER Review Team Members
Evaluation Questionnaire
SBAR Template
Healthcare Governance Committee
SBAR Template
will approve the report and action
plan and identify ongoing monitoring
requirements
SBAR Template
Healthcare Governance Unit will
identify themes and commission
system wide improvement initiatives
and ensure system wide learning.
Leaflet reference: MIS12-300-CC Review date: January 2014
Commitments to patients and families involved in
a Significant Adverse Event
NHS Ayrshire & Arran has agreed what patients and/or carers/families can expect to happen every time
a Significant Adverse Event occurs.
NHS Ayrshire & Arran is committed to ensuring that when a Significant Adverse Event occurs the
immediate crisis will be managed effectively to:
• ensure the patient and their family are safe and supported;
• staff members are safe and supported; and
• the organisation learns from the event and ensures any required improvements are made.
A significant adverse clinical event is any event that resulted in the unexpected death or significant
harm (harm includes negative physical and emotional impact) to a patient. All Significant Adverse
Events will be reviewed in accordance with NHS Ayrshire & Arran’s agreed process.
NHS Ayrshire & Arran recognises the significant impact that such an adverse event will have on patients
and/or their carers/family. The organisational response to such an event will be:
• compassionate;
• transparent;
• honest;
• timely; and
• consistent
with a focus on the needs of the patient and/or carers/family.
When an event occurs patients and/or their carers/families can expect the following:
• we will keep you informed of our actions from the time that the adverse event happens through to the point when we have identified the learning and improvements to be made;
• we will communicate with you respectfully and honestly, in a way that compassionately acknowledges and recognises the emotional impact of the adverse event on you and your family;
• we will support you by providing a consistent named contact person;
• we will work with you to involve you in the review process, taking account of your preferences and providing you with the opportunity to share details of your experiences with staff to support their learning; and
• we will provide you with a sincere and honest apology for identified failings.
11.
Leaflet reference: MIS12-300-CC Review date: January 2014
Our commitments to staff
Introduction
NHS Ayrshire & Arran has agreed what staff can expect to happen every time a Significant Adverse Event
occurs and what the organisation expects from staff.
NHS Ayrshire & Arran is committed to developing and shaping our organisational culture with values,
beliefs and behaviours that:
• recognise the importance of our staff in delivering quality services;
• support our managers and leaders to value staff, their health, safety and wellbeing; and
• support an honest, fair and just culture underpinned by respect and dignity.
This requires every member of staff to play their part; and to understand their roles, responsibilities
and commitments. For the NHS Board, the revised Staff Governance Standard sets out what it must
achieve in order to continuously improve the fair and effective management of staff. NHS Ayrshire &
Arran recognises the importance of staff governance as a feature of high performance which ensures
that all staff have a positive employment experience in which they are fully engaged with both their
job, their team, and their organisation. Achieving such an outcome will not only have a positive impact
on organisational performance (and therefore on the quality of the services we provide), it is also an
important component in providing all employees with dignity at work. For staff, the Staff Governance
Standard, together with existing staff Codes of Conduct, sets out the responsibilities, standards of
performance and behaviours expected.
Our approach to supporting staff through significant adverse events will reflect these aims and has been
agreed in partnership with staff through the Area Partnership Forum.
Significant Adverse Event Review
NHS Ayrshire & Arran is committed to ensuring that when a Significant Adverse Event occurs the event
will be managed effectively to ensure that:
• the patient and their family are safe and supported;
• staff members are safe and supported;
• the organisation appropriately reviews what happened in an open, fair and thorough way, within defined timelines; and
• learns from the event and implements any required improvements.
Significant Adverse Events are those categorised by the Board as events that may have resulted in
the unexpected death or significant harm (harm includes negative physical and emotional impact) to
a patient or member of staff; and may have required intervention to save life. All Significant Adverse
Events will be reviewed in accordance with NHS Ayrshire & Arran’s agreed process, which uses validated
investigation tools to guide decision making, identify root causes, and determine associated learning.
12.
Leaflet reference: MIS12-300-CC Review date: January 2014
Supporting staff
The Board recognises the impact that a significant adverse event may have on staff and has listened to
feedback from staff. Our commitment to staff is that the Board’s revised approach will be:
• fair and thorough;
• compassionate;
• transparent;
• honest;
• timely and consistent;
while all the time being focussed on the needs of the patient, their family and staff.
The Board’s commitments to staff when a significant adverse event occurs are:
• we will ensure that you are safe and fully supported throughout the process;
• we will communicate with you respectfully and honestly, in a way that compassionately acknowledges and recognises the emotional impact the event may have had on you. This communication will be provided by a named contact person;
• we will work with you to involve you in the review process, listening to your experience and ensuring this informs the process and the resultant learning;
• we will ensure that the review is completed thoroughly, fairly and as quickly as possible;
• we will keep you informed of progress of the significant adverse event review, through your named contact, from the time that the event happens through to the point when we have identified the learning and improvements to be made; and
• we will ensure you receive feedback on the findings, recommendations and wider learning.
In return, the Board’s expectations from staff are:
• ensure that you seek to fully understand the revised process and support its implementation within your area of work;
• if you are required to participate in a review process;
• you fully and actively engage throughout the process from initial review to developing and delivering improvement plans and identifying learning;
• you communicate openly, respectfully and honestly with everyone involved;
• you operate within all relevant professional code of conducts as well as the Board’s code of confidentiality;
• you fully implement any learning and education relevant to your role or sphere of practice; and
• you identify if you need help and support and accept this when it is offered.
13.
Leaflet reference: MIS12-300-CC Review date: January 2014
SAER process - roles and responsibilities
Line or Duty Manager
When a significant adverse event happens, the line or duty manager will follow an agreed checklist to
support the consistent approach to the management of these events:
• in conjunction with the clinician involved, make sure that the patient and situation are safe and
prevent further harm
• ensure the immediate needs of all staff involved have been assessed (including requirement to finish
shift early) and that safe staffing levels have been secured
• ensure on-call Staff Care support has been called and appropriate psychological first aid delivered
e.g. defusing, one-to-one support. Follow up debrief/ support arranged
• ensure all staff involved are offered staff resource pack
• inform the Associate Nurse Director, Associate Medical Director and Executive Nurse / Medical
Director of the occurrence of the event and report the event through the Datix incident reporting
system
• the Head of Occupational Health and Safety should be contacted for advice
Associate Nurse and Medical Directors
When a significant adverse event happens, the line or duty manager will make the Associate Nurse
and Medical Director aware of this and report the event through Datix. The Associate Nurse or Medical
Director will oversee Directorate review, escalation to EMD/END and submission of SBAR. The Associate
Nurse or Medical Director (AND/AMD) will:
• review the information
• take cognisance of any situational factors
• ensure that advice has been sought from the Head of Employment Relations and Head of
Occupational Health & Safety
• will provide the Executive Medical and Nurse Directors with the original Datix and SBAR information,
of their assessment of the event and recommendations regarding progression or not to full SAER.
review.
The Executive Sponsor - Executive Medical / Nurse Director
The Executive Sponsor is responsible for deciding if a full review SAER requires to be commissioned. To
make this decision the Executive Sponsor will:
• review the information received from the Associate Nurse or Medical Director regarding the event.
• take cognisance of the organisations agreed approach to dealing with such events and use expert
professional judgement to decide if the event constituted - unexpected death, significant harm or
had the potential to cause significant harm – this may be seen in situations where a near miss has
occurred.
• ensure that the checklist outlining the rationale for commissioning an SAER is completed and stored
within the integrated organisational system for tracking and monitoring review process and actions.
14.
Leaflet reference: MIS12-300-CC Review date: January 2014
The Corporate Assistant Director (Executive Medical/Nurse Directorates)
When an SAER has been commissioned the Corporate Assistant Director will:
• convene a Leadership Oversight Group (LOG) (see below).
• provide a corporate oversight and guidance role for the SAER team, supporting consistency in
approach.
• ensure timelines are met and monitor progress against agreed organisational procedures
• act as a source of specialist advice in respect of scrutiny and improvement dimensions of SAER
processes
• escalate to Executive Sponsor and Director where issues arise that need resolution to implement
SAER procedures.
• ensure that corporate support resources are allocated to Directorates to implement all elements of
SAER process consistently and reliably
Role and responsibilities of the Leadership Oversight Group (LOG)
The LOG will be chaired by the Executive Sponsor and will be convened to support the Executive
Sponsor to oversee the progress and outcome of the review process. Emphasis will be on consistently
implementing a review model that provides independent scrutiny and effectively involves members
of staff who work in the area where the adverse event took place. In particular there will be a focus on
enabling a consistent approach to delivery of expected timescales, communication, staff and family
involvement and support.
Members of the LOG will be the Executive Sponsor, Director, Corporate Assistant Director, Directorate
AND or AMD, Lead Reviewer, Technical Lead with administrative support in attendance. Where
medicines are involved the Director of Pharmacy should be a member of the LOG
The LOG will:
• meet at the beginning of the review process and again at the end to receive the report. It will meet
on an interim basis if necessary
• develop the Terms of Reference of the review. The Terms of Reference will cover key questions
arising from initial review of the event, taking account of available information
• confirm the Lead Reviewer (from outside the service involved) who has been identified by the
organisation as appropriately skilled and competent in systems analysis.
• identify Subject Matter Expert(s) (this includes clinical and corporate support departments) to
participate in the review process. The Subject Matter Expert(s) will be from the service/clinical
specialty involved, but not from the team directly involved in the episode of care Receive the
investigation report on completion for review and approval The Lead reviewer, AND/AMD from
the area in which the event occurred, the Corporate Assistant Director and the family/ staff contact
person will meet with the family and staff to discuss the findings and recommendations of the report.
15.
Leaflet reference: MIS12-300-CC Review date: January 2014
The Director 2
The Director will:
• make sure that staff involved are aware that SAER has been called.
• ensure that the SAER team has full authorisation to conduct the review and that service managers
likely to be involved are aware of this
• nominate a staff and family contact person. The nominated contact person will update the progress /
status of the review to the family and staff involved.
• facilitate the requirements of the review team that will include, staff statements, records, policies and
releasing staff for interviews if necessary.
• where the investigation raises the possibility of external scrutiny, e.g. Fatal Accident Inquiry or Inquiry
by The Mental Welfare Commission/ HIS, senior staff should be made aware of this immediately. On
receipt of the final SAER report the Director will ensure an action plan is developed. The plan must
be developed in accordance with the agreed format for SAER action plans.
• submit the report to the Executive Medical Director for onward submission to the Healthcare
Governance Committee.
• present the final report and action plan to the Clinical Governance Committee.
• ensure there are structures in place to share learning throughout the Directorate.
The SAER team
The Lead Reviewer will be responsible for conducting the review into the root causes of an adverse
event. The lead reviewer will work closely with the Technical Lead and seek support and guidance where
required from the Corporate Assistant Director.
The review team will:
• carry out a full and thorough systems review using established guidance such as the ‘Systems
Analysis of Clinical Incidents’ (The London Protocol) and the Six Steps of Root Cause Analysis.
• involve subject matter experts as appropriate
• ensure the clinical team involved in the incident have opportunity to provide information
• ensure the checklist is completed in relation to the activity of the SAER team
• ensure the progress / status of the review is kept up to date for the use by the members of the LOG
and the nominated staff and family liaison person.
• provide a clear, comprehensive and structured review report that meets the Terms of Reference and
details findings, conclusions and recommendations.
• they will have recognised knowledge and skills in systems analysis and/or root cause analysis and
have a proven track record in conducting SAER.
• Ensure that recommendations are realistic, stretching but achievable; and that these focus on factors
that were contributory to the harm. Incidental issues should be noted for consideration as part of
organisational learning themes
• request factual accuracy checks from Directorate staff (including management) and patient/family.
16.
2 This may also be other Directors with operational responsibilities, depending upon the nature of the significant adverse
event – eg. Director of Pharmacy, Public Health or Information and Clinical Support Services.
Leaflet reference: MIS12-300-CC Review date: January 2014
The Lead Reviewer
The Lead reviewer will be a senior clinician identified by the organisation as having the necessary skills,
knowledge and attitudes to lead the review of a significant adverse event. They will have recognised
knowledge and skills in systems analysis and/or root cause analysis and have a proven track record in
conducting SAER. They will participate in a rota to ensure planned availability and responsiveness. The
organisation expects that this will be regarded as an integral part of the job demands of senior clinical
posts.
Technical Lead
The Technical Lead is someone with advanced knowledge and skill in relation to systems analysis, RCA,
review strategies and scrutiny. The Technical Lead will:
• work with the Lead Reviewer to ensure that the timeline is created.
• guide and coordinate the team in adopting approaches that meet with defined process (reflecting
their specialist knowledge and familiarity with the process).
• work with the Lead Reviewer to ensure timescales are met
• ensure the report is written in an appropriate format.
SAER Support Coordinator
The SAER Support Coordinator will be responsible for overseeing the flow and recording of the process
on a daily basis. This will include:
• transferring detail of decision making to create SAER site
• assist Corporate Assistant Director to convene LOG
• ensure the progress and status of the review is kept up to date for the use by the members of the
LOG and the nominated staff and family contact person
• record the activity of the team within the SAER monitoring and tracking system
Family Contact Person
The family contact person will provide regular contact with the family to share information and updates
on the progress of the review. The contact person will have the required skills to respectfully disclose
sensitive information. This person may be the Lead Reviewer, this decision will be made by the LOG.
At the family meeting the family will be asked what their wishes are in relation to ongoing contact.
The family contact person will be responsible for documenting this information in the system and for
updating the system with:
• the date and time of contact
• information discussed at those contacts
• actions agreed at those contacts
• recording when actions are delivered and what the action was.
17.
Leaflet reference: MIS12-300-CC Review date: January 2014
Staff Contact Person
The staff contact person will provide regular contact with the staff to share information and update staff
on the progress of the review. The contact person will have the required skills to respectfully disclose
sensitive information.
At the Staff meeting, the staff will be advised who the contact person is and how to contact them. The
contact person will be responsible for documenting this information in relation to contact with staff and
for updating the system with;
• the date and time of contacts
• information discussed at those contacts
• any actions agreed at those contacts recording when actions are delivered and what the action was
18.
Leaflet reference: MIS12-300-CC Review date: January 2014
Datix adverse event / near miss reporting and escalation process:
Immediate action guidance
This guidance includes out of hours contact
Adverse event or
Immediate action

near miss occurs
• Keep yourself safe.

• Raise the alarm for help from
others (if applicable)
• Make person(s) / area safe
• Label and remove equipment
involved
• Report
Initial assessment of
consequence impact
If you have answered ‘yes’ to the
question about death or significant
harm then the consequence score must
be either MAJOR or EXTREME.
For all other adverse events determine
the consequence impact by choosing a
colour below.

1 - Insignificant or
2 - minor
Injury requiring no or
some first aid
Clinical outcome or
reduced quality of
patient experience not
related / directly related
to care delivery – readily
resolvable
Short term low staff
levels results in minor
impact to service /
patient care
Short term disruption
in service with minor
impact to patient care /
project / objective
Organisational financial
loss < £10 k
Local media short term
adverse publicity
3 - Moderate
4 - Major
5 - Extreme
Injury requiring clinical Significant harm
treatment / intervention requiring intervention
to save life
Clinical outcome
Adverse event leading
to actual death or
potential for death
affecting service / safe
delivery of patient care
Adverse clinical
outcome resulting in
continued ongoing long
term effects
resulting in short term
Major injury or injury
adverse effects - expect likely to result in long
recovery < 1week
term incapacity /
Ongoing low staff levels disability
Adverse clinical
outcome resulting
in long term effects
- expect recovery >
1week
Disruption in service
with significant impact
to delivery of patient
care / project / objective Sustained loss of service
Organisational financial which has serious
impact on delivery of
loss £10-100 k
patient care / objective /
Local media long term
project
adverse publicity
Organisational financial
loss £100 k-1m
Adverse event leading
to major or permanent
incapacity / disability
Permanent loss of core
service / facility
Organisational financial
loss >£1m
National media adverse
publicity >3 days and
or MP/MSP concern /
question
National media adverse
publicity <3 days
19.
Leaflet reference: MIS12-300-CC Review date: January 2014
Action and escalation
Reporter Action:
Action and escalation
Reporter Action:
Action and escalation
Reporter Action:
Action and escalation
Reporter Action:
Complete on-line Datix
Form
Immediately inform your
shift / line manager or
supervisor
Immediately inform your
shift / line manager or
supervisor
Immediately inform your
shift / line manager or
supervisor
Complete on-line Datix
Form
Ensure the scene is
left undisturbed until
informed otherwise
Ensure the scene is
left undisturbed until
informed otherwise
Complete on-line Datix
Form
Complete on-line Datix
Form
Shift / line manager or
supervisor must:
Shift / line manager or
supervisor must:
Notify Manager - Who
will refer to Immediate
Notify Manager - Who
will refer to Immediate
Escalation to relevant
Directors; Inform and
seek advice from Head
of Communications and
Head of Occupational
Health and Safety.
Escalation to relevant
Directors; Inform and
seek advice from Head
of Communications and
Head of Occupational
Health and Safety.
Ensure the scene is
left undisturbed until
informed otherwise
Ensure the scene is
left undisturbed until
informed otherwise
Contact police if required
Contact police if required
Request written
information from staff to
be provided
Request written
information from staff to
be provided
Check on-line Datix
Form completed
Check on-line Datix
Form completed
Inform your line
manager or supervisor
next available
opportunity
Shift / line manager or
supervisor must:
Consider escalating
further
Consider taking staff
statements
Management Actions
Checklist
20.
Management Actions
Checklist
Leaflet reference: MIS12-300-CC Review date: January 2014
Checklist for immediate management actions following a Significant
Adverse Event
The following checklist is an aide memoire to support managers with the Significant Adverse Event
Review process. A significant adverse event relates to NHS Ayrshire and Arran’s list of mandatory distinct
reportable events and all adverse events attracting a consequence score Major or Extreme. This checklist
is based on best practice and focuses on the three priority elements of the patient and family, the staff
and the organisation.
Date:
Time:
Manager completing checklist:
Patient Name:
CHI Number:
Incident Date:
Datix Ref Number:
Consequence Score:
Directorate
Service:
Speciality:
Location:
Immediate action
Assess the situation
Tick √ Comments if - No or N/A
• Ensure appropriate actions taken to establish a safe environment

• Ensure the safety of individual/s (patient’s / staff / visitors)

• Ensure clinical needs of patient have been assessed and met

• Ensure the patient’s named medical consultant has been notified

• Ensure patient clinical record is complete (nursing & medical)
Communication

• Escalate to Executive Medical / Executive Nurse Director

• Escalate to Director

• Escalate to Associate Medical or Associate Nurse Director

• Escalate to any other relevant Director (if non-clinical incident)

• Inform and seek advice of Head of Communications, Head of
Occupational Health and Safety

• Any other relevant external Agency e.g. Procurator Fiscal,
Strathclyde Police

• Where a medicine is involved escalate to the Director of Pharmacy
Preserve the scene until it has been:

• Physically assessed and/or photographed

• Isolate / remove / label any equipment involved

• Released for use by an appropriately authorised person (eg. police
officer, HSE Inspector, Senior Manager)

Yes
Yes
Yes
21.
Leaflet reference: MIS12-300-CC Review date: January 2014
Patient and family support
Yes
• Ensure the patient/family have been notified of the event and of
action taken

• Offer to meet with the patient/family to discuss the event

• Contact religious/spiritual advisor if requested by relative e.g.
chaplaincy / CISM
Staff support

• Ensure staff needs have been assessed and met - Are they able to
continue with their duties?

• Issue staff with the Staff Support Resource Pack /details of support
available

• Ensure that all staff involved have immediate access to CISM if
requested for appropriate psychological / emotional support
Organisation

• Ensure adequate staffing levels if staff involved are unable to
continue their duties. Redeploy/Call in staff as necessary
Yes
Yes

• Notify the Critical Incident Stress Management (CISM) Coordinator of 
event
• Ensure the adverse event is recorded in the Datix incident system
within 6 hours

• Ensure patient clinical record is complete with any omissions added
as a retrospective record

• Ensure that the patient clinical record is photocopied if the original is 
no longer clinically required for the patient’s care at this time
22.
• Ensure the process for collection of written information is initiated
(eg staff written statements)

• Write an SBAR, Using the Checklist for Decision Making in
Commissioning a Significant Adverse Event Review

Leaflet reference: MIS12-300-CC Review date: January 2014
Checklist for decision making in commissioning a Significant Adverse Event
Review
SAER reporting and decision form
Date of incident:
Date escalated to AMD/AND:
Patient name:
CHI number:
Incident date:
Datix ref number:
Consequence score:
Directorate
Service:
Speciality:
Location:
SBAR communication
Situation
Background
Assessment
Yes
The event is on the organisation’s list of distinct
adverse events that must always be submitted for
review.
The adverse event has attracted a consequence score
of ‘Major’ or ‘Extreme’.
There has been an unexpected death.
No
23.
Leaflet reference: MIS12-300-CC Review date: January 2014
Assessment
Yes
No
Advice has been sought from the Head of Employment
Relations and Head of Occupational Health and Safety
There has been significant harm either physical or
emotional.
The event required intervention was required to save
life.
There is a potential wider impact which may result in
harm to a significant number of patients.
The event requires that an external agency be notified,
such as the health and safety executive.
The Event Potentially raises child protection issues.
The event potentially raises adult protection issues,
specifically:
• Abuse or neglect is known or suspected to be a
factor in the death of the adult at risk which may
include chronic health conditions going untreated.
• The death is by suicide or accidental death or failure
to obtain appropriate care or medical treatment
which may include significant undiagnosed mental
health problems or dangerous assumptions that
a person had capacity for decision making that in
retrospect may be unlikely.
• The death is an alleged murder, culpable homicide,
reckless conduct or act of violence
Recommendation
Completed by
Date
A significant adverse event relates to NHS Ayrshire & Arran’s list of distinct reportable events and/or all
adverse events attracting a consequence score of ‘Major’ or ‘Extreme’.
24.
The rationale to initiate an SAER is based on best practice and focuses on the three priority elements of
unexpected death, significant harm (harm includes negative physical and emotional impact to a patient
and family) or which may have required intervention to save life.
Leaflet reference: MIS12-300-CC Review date: January 2014
Executive Director completing:
Date:
Rationale for decision
Does the Executive Sponsor agree with the AMD and AND recommendations?
Yes
No
Yes
No
Rationale for progressing to SAER
Rationale for not progressing to SAER
For further action
• by Directorate
• Other
• Corporate Assistant Director:
• Lead Reviewer:
25.
Leaflet reference: MIS12-300-CC Review date: January 2014
Checklist for process of managing a Significant Adverse Event Review
The following checklist is an aide memoire to support Corporate Assistant Director with the Significant
Adverse Event Review process. This checklist is based on best practice and focuses on the three priority
elements of the patient and family, the staff and the organisation.
Datix ref number:
SAER ref number:
Person completing checklist:
Corporate Assistant Director:
Executive Nurse/Medical Director Sponsor:
Technical Lead:
Responsible Director:
Lead Reviewer / Family contact:
Staff contact:
Dimensions
Internal Notification (pre 1st LOG meeting)
• Leadership Oversight Group (LOG) meeting arranged within 3
working days (in accordance with rota)
• Appoint Lead Reviewer (in accordance with rota)
• Appoint technical lead (in accordance with rota)
• Director to nominate directorate staff contact person
• Lead Reviewer appointed as family contact person
Leadership Oversight Group (LOG) 1st meeting
• LOG confirms the following roles
• Technical Lead
• Family Contact Person (if not Lead Reviewer)
• Staff Contact Person
• Subject Expert(s)
• LOG confirms HR and Occupational Health and Safety issues
considered at SAER declaration
• Develop draft Terms of Reference (TOR)
Patient / Family meetings:
• Ensure family contact initiated
• Family involvement and communication preferences documented
• Next family contact agreed
26.
Date
Comments if - No
or N/A
Leaflet reference: MIS12-300-CC Review date: January 2014
Staff meetings:
• Ensure staff contact initiated
• Staff involvement and communication preferences documented
• Next staff contact agreed
Leadership Oversight Group (LOG) 2nd meeting
• Meet within 5 working days of the submission of the report.
• Review report to ensure TOR and patient / family / staff comments
are considered
• Confirm SAER process followed and consider recommendations
• Confirm factual accuracy feedback received to inform report.
Systems analysis
• Review is conducted in accordance with the checklist for
implementing systems analysis.
• Technical Lead to ensure that all implementation resources are
available to those who require them.
Executive Sponsorship approval process
• Ensure patient / family / staff comments are included in final report
• Final draft report signed off by Executive Sponsor
Formal feedback to patient / family
• Report sent to family and meeting arranged with 10 working days
• Corporate Lead; Lead Reviewer and subject expert (if applicable) to
provide formal feedback to family
Formal feedback to staff
• Redacted report sent to staff involved and invitation to attend
feedback session within 10 working days
• Director to arrange formal feedback session within 10 working days
Dissemination of final report and development of action plan
• Final report to responsible Director(s)
• Director arranges development of the action plan
• Director monitors progress
• Director arranges to present report and action plan at Healthcare
Governance Committee
27.
Leaflet reference: MIS12-300-CC Review date: January 2014
Checklist for implementing system analysis
Patient Name:
Directorate:
CHI Number:
Service:
Incident Date:
Speciality:
Datix Ref:
Location:
SAE on list (Yes/No):
Consequence score:
Date
Action
Yes
Started
Step 1 – Organisation and Data Gathering
• Collect all healthcare records
q
• Collect relevant protocols and procedures
q
• Request information from staff regarding sequence of
event
q
• Identify and collect other relevant information (e.g.
staff notes)
q
• Ensure all information is stored in SAER System
q
• Arrange staff interviews (insert London extract)
q
Step 2 – Determine the Chronology of the Incident
Use all sources of information to develop chronology of
events
• narrative element
• timeline
• time person grid
• flow charts
q
q
q
q
Step 3 – Identify Clinical Delivery Problems (CDPs)
• Facilitate discussion on possible care delivery problems ❏
• Include all those involved
28.
❏
Comments if – No or
N/A
Leaflet reference: MIS12-300-CC Review date: January 2014
Step 4 – Identify the Contributory Factors
For each CDP, identify contributory factors
❏
Consider use of
• Fishbone diagram
❏
• chronological mapping
❏
• Five whys
❏
• Use Yorkshire Contributory Factor Framework (YCFF) to ❏
identify possible contributions
❏
• Analysis complete
Step 5 – Making recommendations
• Consider involving the service when developing the
recommendations
• Do they map against each contributory factor?
• Is there at least one recommendation for each
contributory factor?
❏
❏
❏
29.
Leaflet reference: MIS12-300-CC Review date: January 2014
Incident Investigation in Hospitals
Yorkshire Contributory Factors Framework (YCFF)
Version 1.6
Based on : BMJ Quality & Safety – March 2012 – doi:10.1136/bmjqs-2011-000443
CONTRIBUTORY FACTOR DOMAIN
Situational Factors
Team Factors
For example:
• Conflicting team goals
• Lack of respect for colleagues
• Poor delegation
• Absence of feedback
Relevant to
Incident?
□ Yes
Individual Staff Factors
For example:
• Fatigue
• Stress
• Rushed
• Distraction
• Inexperience
□ Yes
Task Characteristics
For example:
• Unfamiliar task
• Difficult task
• Monotonous task
□ Yes
Patient Factors
For example:
• Language barrier
• Uncooperative
• Complex medical history
• Unusual physiology
• Intoxicated
□ Yes
CONTRIBUTORY FACTOR DOMAIN
Local Working Conditions
Workload & Staffing issues
For example:
• High unit workload
• Insufficient staff
• Unable to contact staff
• Staff sickness
Relevant to
Incident?
□ Yes
Prompting question
Did the staff involved function as a team?
□ Maybe
□ No
On the day of the incident, how did you feel?
□ Maybe
□ No
Did the task features make to incident more likely?
□ Maybe
□ No
□ Maybe
Were there any reasons this incident was more
likely to occur to this particular patient?
□ No
□ Maybe
Prompting question
Did staff provision match the expected workload
around the time of the incident?
□ No
30.
R Lawton, R McEachan, J Anderson & PA Laloë – Yorkshire Quality & Safety Research Group
Leaflet reference: MIS12-300-CC Review date: January 2014
CONTRIBUTORY FACTOR DOMAIN
Local Working Conditions
Leadership, Supervision & Roles
For example:
• Inappropriate delegation
• Unclear responsibilities
• Remote supervision
Relevant to
Incident?
□ Yes
Drugs, Equipment & Supplies
For example:
• Unavailable drugs
• Equipment not working
• Inadequate maintenance
• No supplies delivery
□ Yes
CONTRIBUTORY FACTOR DOMAIN
Latent/Organisational Factors
Physical Environment
For example:
• Poor layout
• Lack of space
• Excessive noise / heat / cold
• Poor visibility (e.g. position of nurses’
station)
• Poor lighting
• Poor access to patient
Relevant to
Incident?
□ Yes
Support from other departments
This includes support from IT, HR,
porters, estates or clinical services such
as radiology, phlebotomy, pharmacy,
biochemistry, blood bank, microbiology,
physiotherapy, medical or surgical subspecialities, theatres, GP, ambulance…
□ Yes
Scheduling & Bed Management
For example:
• Delay in the provision of care
• Transfer to inappropriate ward
• Difficulties finding a bed
• Lack of out-of-hours support
□ Yes
Staff Training & Education
For example
• Inadequate training
• No protected time for teaching
• Training not standardised
• No regular/yearly updates
□ Yes
Prompting question
Did everyone understand their role?
□ Maybe
□ No
□ Maybe
Were the correct drugs, equipment & supplies
available and working properly?
□ No
□ Maybe
Prompting question
Did the ward environment hinder your work in any
way?
□ No
Were there any problems from other departments?
□ Maybe
□ No
□ Maybe
Did any time or bed pressures play a role in the
incident?
□ No
Were there any issues with staff skill or knowledge?
□ Maybe
□ No
31.
Leaflet reference: MIS12-300-CC Review date: January 2014
32.
CONTRIBUTORY FACTOR DOMAIN
Latent/Organisational Factors
Local Policies, Protocols & Procedures
For example:
• No protocol exists
• Protocol too complicated
• Lack of standardisation
• Contradictory policies exist
Relevant to
Incident?
□ Yes
CONTRIBUTORY FACTOR DOMAIN
Latent/External Factors
Design of Equipment, Supplies & Drugs
For example:
• Confusing equipment design
• Equipment not fit for purpose
• Similar drug names
• Ambiguous labelling & packaging
Relevant to
Incident?
□ Yes
National Policies
For example:
• Commissioned resources
• National screening policy
• Interference by government
organisations
• National medical / nursing standards
• 4 hour Emergency Department target
□ Yes
CONTRIBUTORY FACTOR DOMAIN
General Factors
Safety Culture
For example:
• Patient safety awareness
• Fear of documenting errors
• Attitude to risk management
Relevant to
Incident?
□ Yes
Communication
Written and Verbal Communication
For example:
• Poor communication between staff
• Handover problems
• Lack of communication/notes
• Unable to read notes
• Inappropriate abbreviations used
• Unable to contact correct staff
• Notes availability
□ Yes
Prompting question
Did local policies & protocols help or hinder?
□ Maybe
□ No
□ Maybe
Prompting question
Is there any characteristic about the equipment,
disposables or drugs used that was unhelpful?
□ No
Have any national policies influenced this incident?
□ Maybe
□ No
□ Maybe
Prompting question
How would you describe the culture of your clinical
area in relation to patient safety?
□ No
Were the notes available, accurate & readable?
□ Maybe
□ No
Did poor or absent verbal communication worsen
the situation?
Leaflet reference: MIS12-300-CC Review date: January 2014
Guidance on disclosure of confidential information from Significant
Adverse Event Reviews
This document provides guidance on the disclosure of confidential information gathered during
Significant Adverse Event Reviews. First, frequently asked questions are outlined; second, some general
principles to consider in relation to information from SAERs; and finally some background details on the
laws governing the disclosure and sharing of confidential information obtained during a review will be
outlined. Details of additional resources and sources of advice are outlined at the end of this document.
Frequently asked questions about disclosure of confidential information arising from
SAERs
Can I give unredacted copies of an SAER report to all members of a family ?
No. Unredacted copies of an SAER report can be given to a patient’s nominated family member, and
other family members if the relevant consent is in place. The only content of a report provided to a
family that would be redacted would be personal information relating to staff that a family was not
entitled to.
Can I give copies of a full unredacted SAER report to all of the people directly involved with the
event ?
Not if the report contains personal information about individuals who have not consented for this
information to be disclosed. Redacted copies can be provided to all staff involved. Unredacted copies
can only be provided when all consents are in place or when the people being given the confidential
information already know it by virtue of their existing need to know (e.g. having been a doctor or nurse
involved with the case that the SAER refers to).
Can I send the full SAER report round my team to support the need for learning from the SAER ?
Redacted copies of the SAER (with all personal information removed) can be sent round teams to
support learning and improvement actions.
33.
Leaflet reference: MIS12-300-CC Review date: January 2014
Will a statement that I have provided be shared with the family ?
Statements will not be routinely disclosed to family members unless staff who have provided the
statement consent to this. Family representatives may be provided with a summary of the information
contained within statements.
The following questions will help with thinking and decision-making about sharing information. It may
help to think about these before contacting colleagues for guidance and/or approval for the release of
confidential information for an SAER
Is it OK to disclose adverse event information to the person’s next of kin ?
The term ‘next of kin’ has no legal standing in relation to the issue or the provision of healthcare services.
The right of access to information contained within a health record of someone who has died is granted
on the basis of being the personal representative (which has a legal definition) of the patient, rather
than being a family member or surviving family member. Disclosure of information of a living person
can take place with their consent, or in some circumstances this can be regarded as implied.
Who does the information that you are considering relate to ?
If the information relates to someone who is alive, the Data Protection Act 1998 will govern the sharing
of the information. Personal data shall not be shared unless at least one of the conditions in Schedule 2
is met. If it is deemed to be sensitive personal data then sharing it must be in accordance of Schedules
2 and 3 of the Act. Advice will be provided by the Information Governance Manager and Caldicott
Guardian. If the information relates to a staff member (who is living) then the sharing of the information
will be governed by the Data Protection Act 1998.
34.
Leaflet reference: MIS12-300-CC Review date: January 2014
Does the information relate to a patient who is not alive?
Some of the information gathered during a Significant Adverse Event Review will be regarded as
personal health information and as such sharing will be governed by the Access to Health Records
Act 1990. That is, that sharing of the personal health information can only be with the consent of
the person’s representative. The remaining information will be governed by common law, where
confidentiality is required after death.
Is it possible to remove all details that could lead to people being identified?
If the information is shared or disclosed in a way that means that the person is not identifiable, then
sharing information more widely (such as by means of publication), is possible. Copies of redacted
significant adverse event reports can be shared widely and published if there are no data included that
identify the person(s) involved (directly or by deduction).
If the information is not closely linked with health records information or, in the case of staff, relates
to information generated by or about staff, how do I decide if it constitutes personal data?
In these circumstances, consider whether the information is of biographical significance. This is when
the information relates specifically to the life of a person and this can then identify them when linked
with other details in the document e.g. Mr X worked as a senior policeman. ‘Senior policeman’ is of
biographical significance and could, if linked with other information, lead to deductive identification.
If it is then you will require the consent of the person (or their representative before it can be shared in
anything other than an anonymised form).
Whose personal data do I wish to share?
This could be a patient, relative, staff member involved in care or staff member involved in the review
process. The decisions about disclosure of information will vary depending upon who the information
relates to and who the person(s) are that are requesting the information or to whom it is to be disclosed.
35.
Leaflet reference: MIS12-300-CC Review date: January 2014
To whom am I considering the disclosure or sharing of this information ? Another colleague involved
in the review ? A relative ? A member of the public ?
The person to whom the information is to be disclosed will also determine whether it is legal to do
so. For example, disclosure of personal details of a staff member to a relative who has said they want
to know more about the staff member’s opinions would not be required by law. Disclosure of personal
clinical details to a relative without a patient’s consent (or in the case of someone who has died their
legal representative) would not be legally sanctioned, even if that person claimed that right as a family
member.
How do I get consent from someone to disclose information ?
Consent can be given verbally and then documented that this has happened. The Executive Medical
Directorate liaise with the personal representatives of all deceased patients whose care is subject to an
SAER, to request written consent for sharing of reports with other family members.
Although every scenario generally needs to be considered in accordance with the information in
question and all of the issues outlined here, there are some general principles that the Board will adopt
in relation to disclosure and sharing of information obtained during the course of adverse event reviews.
These are:
• The patient or (in the case of people who have died, the patient’s representative) will determine who
should receive full copies of the review report (including information that identifies the person who is
the subject of the review process).
• The Executive Medical Directorate will prepare redacted copies of all SAER reports for dissemination
across the Board and publication on the Board website. These will have all personal data (as defined
by the Data Protection Act, Access to Health Records Act and common law of confidentiality)
removed. In all other cases, full reports and documentation can be shared with all of those directly
involved with the incident if all of the people whose personal information contained therein have
consented.
36.
Leaflet reference: MIS12-300-CC Review date: January 2014
• The names of staff who were involved with the care of the person(s) whose care is subject to review
will not be publically disclosed in general, though these can be provided to the patient and/or their
personal representatives upon request.
• The names of staff involved in the review of an adverse event can be publically disclosed (unless
there is evidence to suggest that doing so would put staff at risk of harm), as can the names of those
with responsibility for implementing actions arising from the learning and changes required through
the review of adverse events.
• Personal data relating to staff obtained during an adverse event review will not be disclosed to other
people without consent (or in the presence of another legal requirement for disclosure).
• Personal data relating to staff (for example, details that states that a Doctor on duty had previously
experienced stress and depression; or that a nurse had stated that she had been worried about
personal issues on the night of the event) will not be shared publically when referenced in relation to a significant adverse event review.
Staff members usually provide written accounts of events, these often contain a combination of
personal data about patients, third party individuals and staff themselves. Patients and their legal
representatives can be provided with copies of these if the people consent to the elements that
constitute personal data being disclosed. If they do not consent to this, patients and their legal
representatives have a right to receive summaries of the information contained within the written
accounts/statements and will be provided with this.
In view of the wide range of factors that can influence decision-making and the application of the laws
referred to here, advice should be sought on a case by case basis and/or if there are any uncertainties.
37.
Leaflet reference: MIS12-300-CC Review date: January 2013
Laws governing confidential information from Significant Adverse Event Reviews
Information obtained during adverse event review is confidential 31 and, as such, sharing or disclosing
adverse event related information to others is subject to legal requirements. These are outlined in the
Data Protection Act 1998, Access to Health Records Act 1990, Human Rights Act 1998, in common law
and in relation to the Freedom of Information (Scotland) 2002 Act.
Staff members are often uncertain about what information obtained during the course of an
investigation can be disclosed to others. This is an area that is subject to high level of variation in
understanding of the law and there are often very different perceptions of what can be shared.
The Data Protection Act only applies to the personal data of people who are still alive. The DPA
distinguishes between two types of data – personal data and sensitive personal data. More stringent
conditions apply to processing sensitive personal data.
Significant amounts of information obtained during adverse event reviews are classified as personal
data – sensitive personal data health information in relation to health and personal information in
relation to staff involved with the incident under review.
The personal information within health records of people who have died is regulated by the Access to
Health Records Act 1990 and also common law obligations because of the nature of the information and
the circumstances in which it has been provided.
Article 8 of the European Convention on Human Rights provides that ‘Everyone has the right to respect
for his private and family life, his home and his correspondence.’
3 This has a specific legal definition in relation to whether information has the necessary quality of
confidence about it and is imparted in circumstances that require an obligation of confidence.
For further information or advice
Information Governance Team, Executive Medical Directorate, NHS Ayrshire & Arran
 Tel: 01292 513693  Email: [email protected]
Assistant Director, Executive Nurse Directorate, NHS Ayrshire & Arran
 Tel: 01292 617084  Email: [email protected]
Freedom of Information Officer, Communications Department, NHS Ayrshire & Arran
 Tel: 01563 826112  Email: [email protected]
38.
Leaflet reference: MIS12-300-CC Review date: January 2013
Evaluation of the Significant
Adverse Events Review process
The evaluation process is focused on the following ‘key’ elements:
• Adherence to the process
• Compliance with the statement of commitment to staff
• Compliance with the statement of commitment to the patient and their family
Methodology
Evaluation will be an ongoing process to assess consistency of application of the process and
supporting documents. It is proposed to take a triangulated approach to facilitate validation
of data through cross verification from more than two sources. The proposed methodology is
outlined below:
Audit of SAER
Documentation
Patient &
Family/Staff
Evaluation
Questionnaire
Patient &
Family/Staff
Interview/
Focus Group
Application
• The Healthcare Governance Unit will audit adherence to the process and completion of all associated documentation following the completion of each SAER
• The Healthcare Governance Unit will invite every member of staff directly involved in the SAER to complete and return an anonymous questionnaire
• The Healthcare Governance Unit will invite the patient and/or the family involved in the SAER to complete and return a questionnaire
• The Patients and Community Relations Team will undertake one-to-one interviews and/
or focus groups with a sample of staff and patient/family involved in the SAER to explore their experience of the process (using an agreed interview template)
Review
An evaluation report will be developed by the Healthcare Governance Unit and tabled at the
Continuous Clinical Improvement Board in order to review and refine of the SAER process. All
stakeholders will receive feedback.
39.
Leaflet reference: MIS12-300-CC Review date: January 2014
SAER staff evaluation questionnaire
Please complete and return in the envelope provided. All responses will be treated in the strictest
confidence.
SAER number:
1.
Immediately following the adverse event I was adequately supported by the organisation.
Totally agree
Agree
Neutral
Disagree
Totally disagree
2.
I was provided with a named contact from the Staff Care Team within 24 hours of the
adverse event happening.
Yes
No
3.
I was provided with the opportunity to attend a full debrief following the adverse event.
Totally agree
4.
Neutral
Disagree
Totally disagree
I had ample opportunity to discuss my personal involvement in the significant adverse
event with members of the review team.
Totally agree
5.
Agree
Agree
Neutral
Disagree
Totally disagree
I was satisfied with my level of involvement in the root cause analysis process.
Totally agree
Agree
Neutral
Disagree
Totally disagree
6.
I received accurate, consistent and timely information about the progress of the significant
adverse review.
Totally agree
Agree
Neutral
Disagree
Totally disagree
7.
I was satisfied with the process of receiving and discussing the findings and
recommendations arising from the significant adverse event.
Totally agree
8.
Neutral
Disagree
Totally disagree
I was treated fairly and consistently throughout the process of reviewing the significant
adverse event.
Totally agree
9.
Agree
Agree
Neutral
Disagree
Totally disagree
Overall I was satisfied with my experience and involvement in the significant adverse event
process.
Totally agree
Agree
Neutral
Disagree
Totally disagree
10. Please provide any additional comments you wish to make regarding any aspect of the
Significant Adverse Event Process
40.
Leaflet reference: MIS12-300-CC Review date: January 2014
If you wish to discuss any aspect of your involvement in the Significant Adverse Event Process
further please contact your line manager or phone the Healthcare Governance Unit on 01292 513664
Thank you for taking the time to complete this questionnaire. Your feedback will inform the
continuous improvement of the process.
This questionnaire focuses on your experience of the Significant Adverse Event Review Process.
Please complete and return in the envelope provided. All responses will be treated in the strictest
confidence.
41.
Leaflet
Leaflet reference:
reference: MIS12-300-CC
MIS12-300-CC Review
Review date:
date: January
January 2014
2013
SAER family evaluation questionnaire
Are you responding as an individual or on behalf of your family (please circle)
Individual
On behalf of your family
SAER number:
1.
I was informed promptly that the adverse event had occurred.
Totally agree
Agree
Neutral
Disagree
Totally disagree
2.
I was promptly provided with information on what had happened and offered the
opportunity to ask questions.
Yes
No
3.
I was satisfied with the information I received regarding the Significant Adverse Event
review process.
Totally agree
Agree
Neutral
Disagree
Totally disagree
4.
I was kept informed of the progress of the review through to the point when we have
identified the learning and improvements to be made.
Totally agree
Agree
Neutral
Disagree
Totally disagree
5.
I was communicated with in a respectful and honest manner, in a way that
compassionately acknowledged and recognised the emotional impact of the adverse event
on my family and me.
Totally agree
Agree
Neutral
Disagree
Totally disagree
6.
I received consistent support from a named contact person.
Totally agree
7.
Disagree
Totally disagree
Agree
Neutral
Disagree
Totally disagree
I was provided with a sincere and honest apology for identified failings.
Totally agree
9.
Neutral
I felt involved in the review process and my preferences were taken into account including
the opportunity to share details of your experiences with staff to support their learning.
Totally agree
8.
Agree
Agree
Neutral
Disagree
Totally disagree
Overall I was satisfied with my experience and involvement in the significant adverse event
process.
Totally agree
Agree
Neutral
Disagree
Totally disagree
10. Please provide any additional comments you wish to make regarding any aspect of the
Significant Adverse Event Process
42.
Leaflet reference: MIS12-300-CC Review date: January 2013
If you wish to discuss any aspect of your involvement in the Significant Adverse Event Process
further please get in touch with your named contact.
Thank you for taking the time to complete this questionnaire. Your feedback will inform the
continuous improvement of the process.
43.
Leaflet
Leaflet reference:
reference: MIS12-300-CC
MIS12-300-CC Review
Review date:
date: January
January 2014
2013
SAER Review Team Members
evaluation questionnaire
SAER number:
Please complete and return in the envelope provided. All responses will be treated in the strictest
confidence.
Lead Reviewer
Technical Lead
Subject matter expert
1.
The SAER SharePoint system was demonstrated to me
Yes
2.
I was able to navigate and obtain all necessary information from the SAER SharePoint system.
Totally agree
3.
Totally disagree
Agree
Neutral
Disagree
Totally disagree
Agree
Neutral
Disagree
Totally disagree
Agree
Neutral
Totally disagree
N/A
I felt supported as the subject matter expert by my manager.
Totally agree
7.
Disagree
I was satisfied with the level of opportunity to contribute to the review process.
Totally agree
6.
Neutral
The Review Team meetings ran to the planned schedule.
Totally agree
5.
Agree
I received timely information about dates of meetings.
Totally agree
4.
No
Agree
Neutral
Disagree
Totally disagree
Disagree
Totally disagree
I felt supported by others in the SAER Review Team
Totally agree
Agree
Neutral
8.
I was adequately supported by my manager in relation to releasing time to participate in the
review process.
Totally agree
Agree
Neutral
Disagree
Totally disagree
9.
I felt that the review process was achievable within the timescale.
Totally agree
Agree
Neutral
Disagree
Totally disagree
10. I was satisfied that the Leadership Oversight Group respected the Review Team’s opinion (report).
Totally agree
11.
Neutral
Disagree
Totally disagree
I received feedback following the final Leadership Oversight Group meeting.
Totally agree
44.
Agree
Agree
Neutral
Disagree
Totally disagree
Leaflet reference: MIS12-300-CC Review date: January 2013
12. I was advised timeously that the report had been accepted / approved by the Leadership
Oversight Group.
Totally agree
Agree
Neutral
Disagree
Totally disagree
13. I had the opportunity to attend a debrief of the review process.
Totally agree
Agree
Neutral
Disagree
Totally disagree
14. Overall, I was satisfied with my experience with the SAER process
Totally agree
Agree
Neutral
Disagree
Totally disagree
15. Overall I was satisfied with my involvement with the SAER Process.
Totally agree
Agree
Neutral
Disagree
Totally disagree
16. Please provide any additional comments you wish to make regarding any aspect of the SAER
process including any suggestions for improvement.
Thank you for taking the time to complete this questionnaire. Your feedback will inform the continuous
improvement of the process.
This questionnaire focuses on your experience of the Significant Adverse Event Review Process. Please
complete and return in the envelope provided. All responses will be treated in the strictest confidence.
45.
Leaflet reference: MIS12-300-CC Review date: January 2014
Guidance Document for
NHS Ayrshire and Arran
Action Plans
Please Note – If you are using a paper copy of this document you must check AthenA
to ensure that you have the most up to date version
46.
File Name: ActionPlanGuidance300113
Produced by: Healthcare Quality
Version: 8
Page 1 of
Date: 14/05/2013
Review Date: 03/05/2014
Leaflet reference: MIS12-300-CC Review date: January 2014
INTRODUCTION
This document provides guidance in completing all Action Plans within NHS Ayrshire and
Arran. It introduces the template designed to document the status of an action plan and detail
specific evidence of progress towards implementation. The importance of completing each
column is outlined below.
•
Appendix 1 provides an example of an Action Plan.
•
Appendix 2 provides an Action Plan Template ready for use.
THE ACTION PLAN TEMPLATE
Recommendation(s)
In this section the recommendation(s) from a report such as Significant Adverse Event
Reviews (SAER), complaints, Scottish Public Service Ombudsman (SPSO), inspection or local
review should be entered. Each recommendation should be numbered accordingly.
Action(s)
Action(s) should be linked to each recommendation. For example if Recommendation 1.0 has
3 actions then number as Action 1.1, Action 1.2 and Action 1.3.
Target Date for Completion
Enter a specific date when the action will have been completed. For example record as 31st
March 2013 and not March 2013.
Responsible Officer
Include the job title/role of the person responsible for implementation.
Evidence of Effective Implementation
At the point of creating the action plan this is the description of the evidence that will be sought
to confirm that the action has been effectively implemented. Evidence should be aligned to
each action. When the action has been closed the details of the evidence in support of
effective implementation needs to be included. Documents supporting evidence of effective
implementation should be embedded within the action plan. To embed a Word Document
please follow attached instructions:
1.
2.
3.
4.
5.
6.
7.
Go to Insert on the menu bar
Select Object
Select Tab “Create from File”
Tick box “Display as icon”
Browse and then find where the relevant is saved on the PC
Highlight the document and then click on “Insert” and “OK”
The document will then be inserted into the action plan.
N.B. On occasions, the message “Word cannot start the converter mswrd632” will appear with two options –
“Show Help” or “OK”. Continue to click on “OK” until the document is inserted. f the embedded document then
proves difficult to open, right click the document and select “Document Object” and select “Open”.
File Name: ActionPlanGuidance300113
Produced by: Healthcare Quality
Version: 8
Page 2 of
Date: 14/05/2013
Review Date: 03/05/2014
47.
Leaflet reference: MIS12-300-CC Review date: January 2014
Action Status
The status of each action should be recorded as either Open or Closed. If the action is
ongoing i.e. monthly results to be produced ... the status of this action should be recorded as
open. If an action is completed prior to the Target Date for completion, the status should still
be recorded as closed.
Longer action plans
If an action plan contains an extended amount of text and extends over two or more pages,
correct formatting should be included for reasons of clarity and ease of reading.
To do this:
1.
2.
3.
4.
Highlight the row in the table which contains the appropriate column headings.
Right click this row, and from the pop-up menu select “Table Properties…”
From the pop-up window select the “Row” tab.
Ensure the checkbox next to “Repeat as header row at the top of each page” has a tick.
An example of this can be seen in Appendix 2, where the action plan extends over two pages.
48.
Leaflet reference: MIS12-300-CC Review date: January 2014
Guidance on the development of actions
When actions are developed from recommendations it is important to keep in mind some
general guidance to afford them optimal chance of success. Actions that are SMART (Specific,
Measurable, Achievable, Relevant, and Timely) are likely to be achieved. SMART actions
provide a way of ensuring everyone understands them, they are trackable, relevant, there are
enough resources to achieve them and a firm deadline is set.
Specific
Actions should specify what they need to achieve. This means that the action should be clear
and unambiguous. A specific action has a much greater chance of being accomplished than a
general one. To make actions specific, they must tell a team exactly what is expected, why is
it important, who is involved, where is it going to happen and which attributes are important.
Specific in the context of developing actions means that a behaviour, achievement or
observable action is described which is also linked to a rate, number, percentage or frequency.
To increase specificity use verbs which are action-orientated to describe what should be
undertaken to fulfil objectives.
Action verbs include:
•
•
•
•
•
•
•
•
Analyse
apply
change
create
determine
differentiate
identify
perform
Avoid jargon, words and phrases which are (or can be construed as) misleading or ambiguous
such as:
•
•
•
be aware of
have an awareness of
be prepared for a variety of
Measurable
You should be able to measure whether you are meeting the action or not. To do that, a
system, method or procedure has to exist which allows the tracking and recording of the
behaviour or action. Setting an action/goal that requires phone calls to be answered within one
minute is acceptable, provided a system exists which measures whether this is actually being
achieved. If none exists, the manager should be prepared to set time aside time to monitor the
response rates to incoming phone calls.
49.
Leaflet reference: MIS12-300-CC Review date: January 2014
A measurable action will usually answer questions such as:
•
•
•
How much?
How many?
How will I know when it is accomplished?
Measurable is the most important consideration. You will know that you've achieved your
action/goal, because here is the evidence.
Achievable
The actions/goals that are set with people need to be capable of being reached, put most
basically; there is a likelihood of success but that does not mean that they are easy or
simple. They still need to be stretching and agreed by the parties involved.
Achievable is linked to measurable. Usually, there's no point in starting a job you know you
can't finish, or one where you can't tell if or when you've finished it. How can I decide if it's
achievable?
•
•
•
•
•
You know it is measurable
Others have done it successfully (before you, or somewhere else)
It's theoretically possible (i.e. clearly not 'not achievable')
You have the necessary resources, or at least a realistic chance of getting them
You've assessed the limitations.
Relevant
This is focused on choosing actions/goals that matter. A Bank Manager's goal to "Make 40
egg sandwiches by 1.00pm" may be specific, measurable, achievable, and timely, but lacks
relevance. In many instances, the accomplishment of an action/goal requires the support of
others: resources, a champion voice, someone to knock down obstacles. Goals that are
relevant to your team and your organisation will receive that necessary support.
Relevant goals (when met) drive the team, department, and organisation forward. A goal that
supports or is in alignment with other goals would be considered a relevant goal. They should
add useful value within the context in which they are being set, being aligned with strategies
and higher goals.
A relevant action/goal can answer yes to these questions:
•
•
•
Does this seem worthwhile?
Is this the right time?
Does this match our other efforts/needs?
50.
File Name: ActionPlanGuidance300113
Version: 8
Date: 14/05/2013
Leaflet reference: MIS12-300-CC Review date: January 2014
Timely
Commitment to a deadline helps a team focus their efforts on completion of the action/goal on
or before the due date. An action/goal with a deadline is intended to establish a sense of
urgency. This part of the S.M.A.R.T. criteria is intended to prevent goals from being overtaken
by the day-to-day crises that invariably arise in an organisation.
A time-bound goal will usually answer the question:
•
•
•
•
When?
What can I do 6 months from now?
What can I do 6 weeks from now?
What can I do today?
51.
52.
Version: 8
Page 7 of
11
2.1 A report on the findings and
recommendations from the
SPSO report will be circulated to
all department nursing staff.
[evidence: copy of extract from case
notes]
Discussion should be clearly
documented in the patient’s case
notes (With the name, Nursing
Grade / GMC number of the
communicator).
[evidence required: Revised
Discharge letter]
A standardised discharge letter
clearly stating follow up and
discharge medication is in use
across NHS Ayrshire and Arran
Evidence of Effective
Implementation
[evidence: minutes of ward
managers’ meeting December 2012]
Clinical Nurse The SPSO report circulated at the
Manager
Ward Managers Meeting
December 2012.
Date: 14/05/2013
Review Date: 03/05/2014
25th
November
2012
Ward
Managers
25th
November
2012
1.2 Effective communication
between staff and the patient to
ensure they are comfortable
with follow up arrangements
File Name: ActionPlanGuidance300113
Produced by: Healthcare Quality
2.0 Findings and
recommendations from
Scottish Public Services
Ombudsman (SPSO) report
should be shared with staff
for action and/or information
Executive
Medical
Director
31st May
2013
1.1 A standardised discharge
letter will be used across the
organisation with follow up
arrangements and treatment on
discharge
1.0 Discharge letters should
clearly state any follow up
required and by whom, and
detail any medication
required on discharge
Responsible
Officer
Target Date
For
Completion
Action
Recommendation
Action Plan Example A
Closed
Closed
Open
Action
Status
Appendix 1
Leaflet reference: MIS12-300-CC Review date: January 2014
Version: 8
Page 8 of
11
3.1 An audit of nursing
documentation will be
undertaken based on the NMC
guidelines, 5 cases per week
until 95% compliance with
criteria is met.
File Name: ActionPlanGuidance300113
Produced by: Healthcare Quality
3.0 The Board emphasise to
all nursing and midwifery
staff, the importance of
adhering to the Nursing and
Midwifery Council (NMC)
2009 guidelines/record
keeping: guidance for
nursing and midwives
2.2 Ward Managers will discuss
the complaint and the findings of
SPSO with their nursing team.
Ward
Managers
30th
November
2013
Date: 14/05/2013
Review Date: 03/05/2014
Ward
Managers
15th February
2013
[Evidence: run charts produced and
presented to the ward managers /
SMT on a monthly basis]
Audit results will be recorded on a
run chart to monitor improvement.
[Evidence: copy of safety brief /
ward]
Complaint and findings of SPSO
discussed at ward’s daily meeting
and noted on the safety briefing.
Open
Closed
Leaflet reference: MIS12-300-CC Review date: January 2014
53.
54.
1.1 Charge Nurse will lead all
ward rounds taking up-todate information from named
nurse and reporting back on
consultants findings and
decisions
2.1 Supplement monitoring
charts must be completed by
staff allocated and any
refusal/dislikes must be
documented on chart and
reported to Charge Nurse/
Dietitian
1.0 Ward rounds must be
supported by Charge
Nurse/ Nurse in Charge in
leadership/ coordinating
role. This encourages
continuity of care,
identifying and highlighting
any problems/ potential
problems with individual
patients
2.0 Where nutritional
supplements are
prescribed, supplement
monitoring charts must be
used
3.0 Weight must be
3.1 All patients weight, height
recorded and BMI
and BMI should be
accurately calculated for
accurately recorded on
all patients. Patients
admission to ward and MUST
should be reviewed as per assessment completed as
MUST assessment tool
directed with
File Name: ActionPlanGuidance250313v6
Version: 6
Produced by: Healthcare Quality
Page 9 of
11
Action
Recommendation
Action Plan Example B
Ward
Managers
Ward
Managers
30th April
2013
30th June
2013
Date: 25/03/2013
Review Date: 25/03/2014
Ward
Managers
Responsible
Officer
Target Date
For
Completion
31st January
2013
An audit of completion of 5
nursing documentation entries
monthly will demonstrate
recording of height, weight,
BMI and MUST assessment on
admission to ward for every
[Evidence required: audit results
on use of supplement monitoring
charts]
An audit of completion of 5
supplement monitoring charts
demonstrating 100%
compliance must be
undertaken monthly
[Evidence: extract from health
record demonstrating coordinated
approach by Charge Nurse; safety
briefing]
Ward rounds supported by
Charge Nurse, coordinated
information at ward round,
safety briefing/handover and
within patients health record
Evidence of Effective
Implementation
Open
Open
Closed
Action
Status
Appendix 2
Leaflet reference: MIS12-300-CC Review date: January 2014
Version: 6
Page 10 of
11
recommendations followed
Action
File Name: ActionPlanGuidance250313v6
Produced by: Healthcare Quality
Recommendation
Responsible
Officer
Date: 25/03/2013
Review Date: 25/03/2014
Target Date
For
Completion
[Evidence required: audit results]
patient
Evidence of Effective
Implementation
Action
Status
Leaflet reference: MIS12-300-CC Review date: January 2014
55.
56.
File Name: [Document Name]
Produced by: [Author, Service]
4.0
3.0
2.0
1.0
Recommendation
Action Plan Template
Action
Version: [Version No]
Page 11 of 11
Target Date
For
Completion
Responsible
Officer
Date: [Date produced]
Review [Date due for review]
Evidence of Effective
Implementation
Action
Status
Appendix 3
Leaflet reference: MIS12-300-CC Review date: January 2014
Leaflet reference: MIS12-300-CC Review date: January 2014
57.
Significant Adverse Event Reviews
Recommended reading and resources
The following documents are recommended reading for staff wishing more details in respect of the management of Significant
Adverse Events:
Conway J, Federico F, Stewart K, Campbell MJ. Respectful Management of Serious Clinical Adverse Events (Second Edition). IHI
Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2011. (Available at
http://www.ihi.org/knowledge/Pages/IHIWhitePapers/RespectfulManagementSeriousClinicalAEsWhitePaper.aspx). 4
Disclosure of Adverse Events to Patients. Annotated Bibliography.
Available at http://www.ihi.org/knowledge/Pages/Tools/DisclosureofAdverseEventstoPatientsAnnotatedBibliography.aspx 5
Communicating After an Adverse Event.
Available at: http://www.ihi.org/knowledge/Pages/Tools/CommunicatingAfteranAdverseEventBiblio.aspx 6
Conway, J; Sadler, B & Stewart K. (2010). Planning for a Clinical Crisis, Healthcare Executive, Nov/Dec 2010, 78-81.
Available at: http://www.primaris.org/sites/default/files/article_on_clinical_crisis.pdf
Federico, F & Conway, J (2011). Planning for a Clinical Crisis: Next Steps, Healthcare Executive, Nov/Dec 2011, 74-76
Available at: http://www.fadelibrary.org.uk/wp/wp-content/uploads/downloads/2011/10/Planning-for-a-clinical-crisis-Next-steps.pdf
Taylor-Adams, S & Vincent, C. ‘Systems Analysis of Clinical Incidents. The London Protocol’
Available at http://www1.imperial.ac.uk/resources/C85B6574-7E28-4BE6-BE61-E94C3F6243CE/london%20protocol_e.pdf
Mahajan, R. P. (2010). Critical Incident Reporting and Learning, British Journal of Anaesthesia, 105(1), 69-75.
Available at http://bja.oxfordjournals.org/content/105/1/69.full.pdf+html
4 5 6 Note
58.
that registration with IHI required to access this.
Significant Adverse Event Reviews
Recommended reading and resources
Reason, J (2000). Human error: models and management. British Medical Journal, 320, 768-770. (18 March).
Login to Knowledge Network (http://www.knowledge.scot.nhs.uk/home.aspx) and then paper accessible via
http://www.bmj.com/content/320/7237/768.pdf%2Bhtml
Seys, D, Scott, S, Wu, A, Van Gerven, E et al. (2012). Supporting involved healthcare professionals (second victims) following an
adverse health event: A literature review. International Journal of Nursing Studies. Pre-print available from Professor White,
Assistant Director, Executive Medical Directorate by kind permission of the authors.
Seys, D, Wu, A, Van Gerven, E, Vleugels, A et al (2012). Health Care Professionals as Second Victims after Adverse Events: A
Systematic Review, Evaluation & The Health Professions. Pre-print available from Professor White, Assistant Director, Executive
Medical Directorate by kind permission of the authors.
Wojcieszak, D, Saxton, JW & Finkelstein, MM. (2010). Sorry Works. Disclosure, Apology and Relationships Prevent Medical
Malpractice Claims, Bloomington Indiana: AuthorHouse Publications.
The Institute for Healthcare Improvement Knowledge Center has a wide range of further written, audio and visual materials available
at: http://www.ihi.org/knowledge/Pages/Tools/LeadershipResponseSentinelEventEffectiveCrisisMgmt.aspx 7
For general reading materials in relation to Quality Improvement, see
http://www.amazon.co.uk/registry/wishlist/1NWNOL8WGJF21/ref=cm_wl_rlist_go_o_C-2
If you have resources or materials that you think other colleagues would find useful or helpful then please email
[email protected] with details in order that these can be included in a future version of this list of resources.
Executive Nurse Directorate, 01 April 2013.
7 Note
that registration with IHI required to access this.
59.