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    Embedding learning from adverse incidents: a UK case study

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    Publication date
    2017
    Author
    Eshareturi, Cyril
    Serrant, L.
    Keyword
    Root cause analysis; Adverse incidents; Embedding learning; NHS hospital; Reporting system; Soft intelligence
    Rights
    (c) 2017 Emerald Publishing Limited. Full-text reproduced in accordance with the publisher's self-archiving policy.
    Peer-Reviewed
    Yes
    
    Metadata
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    Abstract
    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.
    URI
    http://hdl.handle.net/10454/15224
    Version
    Accepted manuscript
    Citation
    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 publisher’s version
    https://doi.org/10.1108/IJHCQA-05-2016-0060
    Type
    Article
    Collections
    Health Studies Publications

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