Learning from mistakes
Across the NHS, problems sometimes occur while we are looking after you which affect your care. We call these problems incidents, or sometimes, clinical incidents.
Incidents can vary from very small problems, such as a trolley not working as it should, to incidents that result in harm. If an incident is particularly severe, we call it a serious incident.
NHS England requires us to report a serious incident (SI) if something we do (or fail to do) causes:
- a patient to die unexpectedly
- an unexpected or avoidable injury to a patient which leads to them experiencing serious harm
- an unexpected or avoidable injury to a patient which means that they need further treatment to prevent them from dying or experiencing serious harm
- a never event (one of a list of issues which should never occur during our care)
- a problem that prevents us from delivering an acceptable standard of care for our patients.
We are also required to report a serious incident if one of our services doesn’t do enough to prevent someone from being abused, or if abuse occurs while a patient is in our care.
Recognising Serious Incidents
Serious incidents don’t happen often, but when they do, we can identify them in a number of ways, including:
- a report from a staff member which highlights a problem
- information from clinical audits
- feedback from a patient, carer or relative
We ask our staff to report all incidents, even if they didn’t cause any harm, to help us identify areas where we need to make improvements.
Investigating Serious Incidents
We have a strong process for investigating serious incidents, so that we can prevent them from happening again.
If an incident is reported and looks like it might be a serious incident, we will review it to look at:
- what we know about the incident
- if it appears to be a serious incident
- how to investigate it
- who will investigate it
- how we will keep the patient, their carer, or their relatives informed about the investigation as part of our Duty of Candour.
The incident will then be investigated by a senior member of staff who has not previously been involved in the incident. They will usually:
- review clinical records
- collect statements from or interview staff members who had been involved in the incident
- consider any other facts or documents, such as policies.
The senior member of staff will produce a report based on a template, to make sure that it includes all the information we need.
Sharing learning from Serious Incidents
When a serious incident report is finished, we will use its findings to write an action plan. The action plan helps us to change or improve the way we provide care, so that we can stop incident happening again.
It’s important that we share this learning with our teams so that similar problems don’t happen in different services. We share learning in lots of different ways:
- in meetings
- in training sessions
- through departmental newsletters
- in our internal communications, such as our staff e-bulletin, or our intranet
This helps our staff make improvements to our care across our Trust.
Our completed serious incident reports are also reviewed outside the Trust, as we share them with our Clinical Commissioning Groups (CCGs). Our CCGs help us to check that our investigations are thorough and robust, and that the actions that we have agreed are a reasonable response to the problem that caused the incident.