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.

All health and care organisations have a duty to support their staff to report adverse incidents. Health and care 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. 

a. Patient safety incidents in England and Wales are reported to the National Reporting and Learning System, or its replacement, the Learn from patient safety events (LFPSE) service.^{29, 30}  

b. You must use the UK-wide Yellow Card scheme³¹ to inform the Medicines and Healthcare products Regulatory Agency (MHRA) about:

1. serious suspected adverse reactions to a medicine
2. any suspected adverse reactions to products marked with a Black Triangle symbol (▼).³² 

c. Adverse incidents involving medical devices, including those caused by human error, that put, or have the potential to put, the safety of patients, health and care professionals or others at risk must be reported to the medical device safety lead in your organisation (if there is one) and the relevant national body:

1. in England and Wales - MHRA reporting adverse incidents
2. in Northern Ireland - Northern Ireland Adverse Incident Centre
3. in Scotland - Health Facilities Scotland online incident reporting

d. Healthcare Improvement Scotland has a national framework,³³  which aims to support health and social care services in Scotland effectively manage adverse events.

e. The Health and Social Care Board has published a procedure for the reporting and follow-up of serious adverse incidents in Northern Ireland.³⁴ 

f. In England, general practitioners and other primary medical services must submit all notifications³⁵   directly to the Care Quality Commission (CQC).

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. 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.^{36, 37}  

Your organisation has a duty to 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,  you should raise a concern in line with our guidance.^{36, 37}  

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. 

You must take part in regular reviews and audits^{39, 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}