Management of Adverse Events: Review Report NHS Shetland

Reviewing NHS boards’ governance arrangements and processes for managing adverse events helps us to identify whether appropriate learning and improvement is taking place to reduce the risk of events happening again.Our reviews focus on the six key recommendations (18–23) for NHS boards from the NHS Ayrshire & Arran report (2012) to provide assurance that NHS boards are effectively managing adverse events. We measure NHS boards against the recommendations within the NHS Ayrshire & Arran report and against their own policies.Our review of NHS Shetland's governance arrangements and processes for managing adverse events involved: an analysis of evidence provided by the NHS board, and a visit to NHS Shetland on Thursday 18 to Friday 19 April 2013This report highlights areas of strengths as well as areas for further improvement, including recommendations for actions.