#WeNurses - Thursday 24th May 2018 8pm (GMT Standard Time) Learning from serious incidents

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The NHS is one of the busiest organisations in the world, treating over 1 million patients every 36 hours.  We aim to provide the best possible care but unfortunately on rare occasions things can go wrong.  These errors are rarely the fault of individuals but are the actually caused by the systems they work in.

Serious Incidents should accordingly be reported and investigated in the NHS so that action can be taken to prevent the same incident from happening again.

Existing national guidelines describe how the NHS should do a number of things when identifying a Serious Incident, including setting up an investigation team; involving patients, carers and staff; scoping and defining an investigation; developing an action plan and submitting a report to commissioners.

However, evidence from patients, families, carers and staff have revealed weaknesses in the way NHS organisations investigate, communicate and learn when things go wrong.

  • investigations do not always properly involve and support patients, families, carers and staff
  • many are undertaken by staff who do not have the necessary training, or time given their other responsibilities;
  • some focus too narrowly on care in specific settings and do not consider the care a patient received from several different organisations;
  • too often the investigation does not follow a systems-based methodology; and
  • too many make weak recommendations

To support the NHS to address these weaknesses, NHS Improvement wants to talk to frontline staff so they can understand the factors that undermine investigations, and limit their potential as a tool for learning and improvement.  

On the evening of May 24th NHS Improvement will host a #WeNurses Tweetchat to seek your views about how and when the healthcare system should investigate serious incidents. Your involvement is important - feedback will be used to inform the revision of the Serious Incident framework by the end of 2018 which will result in better processes to support staff when things go wrong.

Further details on our engagement can be found on the NHS Improvement website HERE

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