The review will be transparent feedback will be given in a way that best meets the patient/family’s needs with a summary available for them to receive on conclusion of a Significant or Local Adverse Events Review (appendix 5). As a minimum patients/families will be informed that a review is taking place and will be asked what matters to them.

Patients and their families will remain at the heart of care, this includes when an adverse event has occurred. It is not intended for circumstances where a patient’s condition deteriorates due to the natural progression of their illness. The Statutory Duty of Candour (Scottish Government, 2018) is the procedure that organisations providing health services, care services and social work services in Scotland, are required by law to follow when there has been an unintended or unexpected incident arising from the care and/or treatment they have received that results in death or harm (or additional treatment is required to prevent injury that would result in death or harm). Duty of Candour should be a consideration of all adverse event reviews. Adverse event reporting increases as the organisation moves to a more open culture. Reviews of events happen frequently and quickly following their occurrence. Patients, service users and their families are told what went wrong and why and receive an apology for any harm that has occurred. This is important to allow a reflection on the weaknesses of the system, or in the case of near misses, the strengths, and prevention of future events.Įvents are identified, reported and managed in a timely manner.

Opportunities are identified to learn from good practice as well as ALL level of reviews which includes near misses.Īdverse events act as a ‘window’ on the system allowing a systems analysis. The adverse events management process is focused on learning, locally, organisationally and nationally with a primary purpose to improve systems and care and NOT to apportion blame. Access hereġ.1.2 Emphasis on learning and promoting good practice The principles of the policy build on NHS Fife’s key values, which are: to improve health and wellbeing, to improve the quality of health and care services, to improve staff experience and wellbeing and to deliver value and sustainability, and are in line with Learning from adverse events through reporting and review: A national framework for Scotland (July 2018). This policy must be read in conjunction with relevant NHS Fife Health and Safety Policies and Safe use of Medical Sharps Policy (see section 6).

Act 1974, in particular the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 2013 (as amended), the Environmental Protection Act 1990. * The organisation will work in accordance with the Health & Safety at Work etc. RIDDOR reportable incidents, sharps incidents* information governance, adverse publicity and finance unexpected deaths, surgical complication, medication incidents The purpose is to support a consistent and timely approach to the identification, reporting, reviewing and learning from all adverse events and near-misses. The aim of this policy is to minimise the risk of adverse events occurring by maximising opportunities to learn, ensuring patients are kept safe and staff are supported. If you have any questions regarding the content of this document or suggestions for improvement, please send these to Fife Adverse Events mailbox: 1. If a policy is past its review date then the content will remain extant until either such time as the policy review is complete and the new version published. Reviewed policies will have a review date set that is relevant to the content (advised by the author) but will be no longer than 3 years. New policies will be subject to a review date of no more than 1 year from the date of first issue. NHS Fife acknowledges and agrees with the importance of regular and timely review of policy statements and aims to review policies within the timescales set out.

Sentinel event definition 2013