Encouraging a learning culture by reporting errors
When something goes wrong with patient care, it is crucial that it is reported at an early stage so that lessons can be learnt quickly and patients can be protected from harm in the future.
Healthcare organisations should have a policy for reporting adverse incidents and near misses, and you must follow your organisation’s policy.28
A number of reporting systems and schemes exist around the UK for reporting adverse incidents and near misses.
- Adverse and patient safety incidents in England and Wales are reported to the National Reporting and Learning System.29
- You must report suspected adverse drug reactions to the UK-wide Yellow Card Scheme run by the Medicines and Healthcare products Regulatory Agency (MHRA) and the Commission on Human Medicines.30
- You must report adverse incidents involving medical devices to the UK-wide MHRA reporting system.31
- Healthcare Improvement Scotland has a national framework,32 which outlines consistent definitions and a standardised approach to adverse incident management across the NHS in Scotland.
- The procedure for the management and follow-up of serious adverse incidents in Northern Ireland is set out on the Department of Health, Social Services and Public Safety’s website.33
- In England, general practitioners and other primary medical services must submit all notifications34 directly to the Care Quality Commission (CQC).
Medicines and Healthcare products Regulatory Agency Yellow Card: Helping to make medicines safer (accessed 15 June 2015)
Medicines and Healthcare products Regulatory Agency Reporting adverse incidents involving medical devices (accessed 15 June 2015)
Healthcare Improvement Scotland (2015) Learning from adverse events through reporting and review: A national framework for Scotland (accessed 15 June 2015)
Department of Health, Social Services and Public Safety Procedure for the Management and Follow up of Serious Adverse Incidents (accessed 15 June 2015)
Registered providers in England are required to notify the CQC about certain incidents. For more information see the Notifications section on page 15 of the CQC information for all providers.
In addition to contributing to these systems, you should comply with any system for reporting adverse incidents that put patient safety at risk within your organisation (see paragraphs 32–33 on the organisational duty of candour). If your organisation does not have such a system in place, you should speak to your manager and – if necessary – raise a concern in line with our guidance.35
Your organisation should support you to report adverse incidents and near misses routinely. If you do not feel supported to report, and in particular if you are discouraged or prevented from reporting,37 you should raise a concern in line with our guidance.35
You must not try to prevent colleagues or former colleagues from raising concerns about patient safety.38 If you are in a management role, you must make sure that individuals who raise concerns are protected from unfair criticism or action, including any detriment or dismissal.37
A fitness to practise panel is likely to consider a more serious sanction if there is evidence of a failure to raise a concern, or of an attempt to cover up.
You must take part in regular reviews and audits39 40 of the standards and performance of any team you work in, taking steps to resolve any problems. You should also discuss adverse incidents and near misses at your appraisal.41 42
Nursing and Midwifery Council (2015) The Code: Professional standards of practice and behaviour for nurses and midwives (accessed 15 June 2015), section 23
General Medical Council (2012) Supporting information for appraisal and revalidation (accessed 15 June 2015), p8
Additional duties for doctors, nurses and midwives with management responsibilities and for senior or high-profile clinicians
Senior clinicians have a responsibility to set an example and encourage openness and honesty in reporting adverse incidents and near misses. Clinical leaders should actively foster a culture of learning and improvement.43
If you have a management role or responsibility, you must make sure that systems are in place to give early warning of any failure, or potential failure, in the clinical performance of individuals or teams. These should include systems for conducting audits and considering patient feedback. You must make sure that any concerns about the performance of an individual or team are investigated and, if appropriate, addressed quickly and effectively.
If you are managing or leading a team, you should make sure that systems, including auditing and benchmarking, are in place to monitor, review and improve the quality of the team’s work.
- You must work with others to collect and share information on patient experience and outcomes.
- You should make sure that teams you manage are appropriately trained in patient safety and supported to openly report adverse incidents.
- You should make sure that systems or processes are in place so that:
- lessons are learnt from analysing adverse incidents and near misses
- lessons are shared with the healthcare team
- concrete action follows on from learning
- practice is changed where needed.
The organisational duty of candour
All healthcare organisations have a duty to support their staff to report adverse incidents, and to support staff to be open and honest with patients if something goes wrong with their care. Each of the four UK governments has considered ways to implement the organisational duty of candour, with some writing it into law (see appendix 2).
If systems are not in place in your organisation to support staff to report adverse incidents, you should speak to your manager or a senior colleague. If necessary, you should escalate your concern in line with our guidance on raising concerns.35 36