title: Embedding learning from adverse incidents: a UK case study.
abstract: Purpose 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. Design/methodology/approach 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. Findings "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. Practical implications Softer intelligence from adverse incident investigations could be usefully shared between hospitals through a regional forum. Originality/value The use of a database as a tool to facilitate the sharing of learning from adverse incidents across the health economy is not supported.
authors.affiliation: Centre for Health and Social Care Improvement, University of Wolverhampton , Wolverhampton, UK.
authors.forename: Cyril
authors.initials: C
authors.lastname: Eshareturi
authors.affiliation: Faculty of Health and Wellbeing, Sheffield Hallam University , Sheffield, UK.
authors.forename: Laura
authors.initials: L
authors.lastname: Serrant
mesh_terms: D006801:Humans; D007407:Interviews as Topic; D019300:Medical Errors / Q000517:prevention & control; D019982:Organizational Case Studies; D058996:Quality Improvement / Q000458:organization & administration*; D012308:Risk Management / Q000458:organization & administration*; D060891:Root Cause Analysis / Q000458:organization & administration*; D017751:Safety Management / Q000458:organization & administration; D013997:Time Factors; D006113:United Kingdom; D016526:Workload
keywords: Adverse incidents; Embedding learning; NHS hospital; Reporting system; Root cause analysis; Soft intelligence