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A new framework for managing and learning from adverse events in the NHS is to be put in place across Scotland, it was announced today.

Healthcare Improvement Scotland (HIS) have today published a review of NHS Ayrshire and Arran’s management of adverse events.

The review, requested by Health Secretary Nicola Sturgeon, made a number of recommendations for the board. These have been accepted and the board have today published an improvement plan which will address the recommendations as a matter of urgency.

The report also highlighted areas for national learning and made recommendations for NHSScotland. In light of this a national framework will be developed to support improvement and a more consistent approach to managing and learning from such events will be made available to all health boards.

The new framework will be developed by HIS for NHSScotland and will consider:

• involvement and engagement with the patient and their family
• the support for the staff involved
• the reporting and operational management of the adverse event and
• the organisational learning and improvement that needs to take place as a result.

Ms Sturgeon said:

"NHS Ayrshire and Arran will be taking forward actions to respond to the recommendations of this review as a matter of urgency and have already put in place a detailed improvement plan.

"It is vital that lessons are learned from adverse events in order to improve patient safety and the quality of healthcare services.

"That is why I have instructed that a national framework for the management of adverse events be developed for the first time. We need a consistent approach across NHS Scotland that supports a culture of openness, trust and service quality improvement.

"All Boards must consider the recommendations from the report and the development of the new national framework. Healthcare Improvement Scotland will undertake a rolling programme of reviews over the course of the next 12 months to ensure that appropriate action has taken place."

The Scottish Information Commissioner’s report issued in February 2012 expressed concerns about NHS Ayrshire & Arran’s handling of FOI requests submitted by Mr Rab Wilson and the Board’s records management practices in relation to critical incident reviews and significant adverse events reports (SAERs).

The Health Secretary commissioned two actions as a result of this report:

• NHS Ayrshire & Arran was asked to urgently review their FOI policy and procedures and provide assurances that they were fully compliant with the legislation. In response the Board reviewed their local FOI systems and processes. They have now developed an action plan to update their FOI procedures.
• HIS was asked to carry out a review of relevant clinical governance and risk management arrangements within NHS Ayrshire & Arran. HIS was also asked to consider what opportunities there were for shared learning across NHSScotland in respect of the management of and learning from critical incidents and adverse events.

Related information

• NHS Ayrshire and Arran
• A review of NHS Ayrshire and Arran’s management of adverse events