Healthcare Improvement Scotland The Management of Significant Adverse Events in NHS Ayrshire & Arran report

Rationale behind NHS Ayrshire & Arran report The Cabinet Secretary for Health, Wellbeing and Cities Strategy instructed Healthcare Improvement Scotland to carry out, as a matter of urgency, a review of the clinical governance systems and processes in NHS Ayrshire & Arran, in particular those that relate to their management of critical incidents, adverse events, action planning and local learning. This followed a decision by the Scottish Information Commissioner on 21 February 2012 on NHS Ayrshire & Arran’s response to a Freedom of Information (Scotland) Act appeal regarding critical incident reviews and significant adverse event reviews. Key findings The review group found: a lack of clarity within NHS Ayrshire & Arran on the lines of accountability, reporting and ownership of Significant Adverse Event Review actions and learning, including complex and unwieldy clinical governance structures confusion regarding staff understanding of their scope to share information on significant adverse event reviews and variation in the interpretation of relevant policy and procedural documents – this hampered learning and improvement substantial shortfalls related to staff involvement, action planning and the dissemination of wider learning examples of comprehensive Significant Adverse Event Review Reports, but lack of a robust and systematic approach to implementing action plans and monitoring progress a commitment to involving patients and families, and raise awareness of the need to involve families, but the system that tracks and responds to issues raised by families was an area of weakness and the Review Group found an inconsistent approach within NHS Ayrshire & Arran to family involvement no evidence of a system to identify thematic learning to allow change and improvements to clinical practice, and weaknesses in the way decisions to undertake Significant Adverse Event Reviews were evidenced and documented.