Embedding learning from adverse incidents: a UK based regional case study

ESHARETURI, C and SERRANT, Laura (2017). Embedding learning from adverse incidents: a UK based regional case study. International Journal of Health Care Quality Assurance, 30 (3), 216-223.

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Official URL: http://www.emeraldinsight.com/journal/ijhcqa
Link to published version:: https://doi.org/10.1108/IJHCQA-05-2016-0060


Purpose: This paper reports on a regionally based UK study uncovering what has worked well in learning from adverse incidents in hospitals. It reviews the incident investigation methodology used, identifying strengths or weaknesses and explores the use of a database as a tool to embed learning Design/methodology/approach: Documentary examination was conducted of all adverse incidents reported between 1st June 2011 and 30th June 2012 by three UK National Health Service hospitals. One Root Cause Analysis report per adverse incident for each individual hospital was sent an advisory group for 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 Research limitations/implications: Practical implications: Softer intelligence from adverse incident investigations could be usefully shared between hospitals through a regional forum Social implications: 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

Item Type: Article
Research Institute, Centre or Group: Centre for Health and Social Care Research
Departments: Health and Well-being > Nursing and Midwifery
Identification Number: https://doi.org/10.1108/IJHCQA-05-2016-0060
Depositing User: Laura Serrant
Date Deposited: 28 Nov 2016 12:44
Last Modified: 28 Jan 2018 08:14
URI: http://shura.shu.ac.uk/id/eprint/14125

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