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Publication date
2017Keyword
Root cause analysisAdverse incidents
Embedding learning
NHS hospital
Reporting system
Soft intelligence
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(c) 2017 Emerald Publishing Limited. Full-text reproduced in accordance with the publisher's self-archiving policy.Peer-Reviewed
YesOpen Access status
openAccess
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Show full item recordAbstract
This paper reports on a regionally based UK study uncovering what has worked well in learning from adverse incidents in hospitals. The purpose of this paper is to review the incident investigation methodology used in identifying strengths or weaknesses and explore the use of a database as a tool to embed learning. Documentary examination was conducted of all adverse incidents reported between 1 June 2011 and 30 June 2012 by three UK National Health Service hospitals. One root cause analysis report per adverse incident for each individual hospital was sent to an advisory group for a review. Using terms of reference supplied, the advisory group feedback was analysed using an inductive thematic approach. The emergent themes led to the generation of questions which informed seven in-depth semi-structured interviews. “Time” and “work pressures” were identified as barriers to using adverse incident investigations as tools for quality enhancement. Methodologically, a weakness in approach was that no criteria influenced the techniques which were used in investigating adverse incidents. Regarding the sharing of learning, the use of a database as a tool to embed learning across the region was not supported. Softer intelligence from adverse incident investigations could be usefully shared between hospitals through a regional forum. The use of a database as a tool to facilitate the sharing of learning from adverse incidents across the health economy is not supported.Version
Accepted manuscriptCitation
Eshareturi C and Serrant L (2017) Embedding learning from adverse incidents: a UK case study. International Journal of Health Care Quality Assurance. 30(3): 2016-223.Link to Version of Record
https://doi.org/10.1108/IJHCQA-05-2016-0060Type
Articleae974a485f413a2113503eed53cd6c53
https://doi.org/10.1108/IJHCQA-05-2016-0060