Sai
Recommendations related to sai
Tag overview
recommendation across 1 inquiry
Across 1 inquiry
Tagged Recommendations
SAI Reporting Understanding
Trusts should ensure that all healthcare professionals understand what is expected of them in relation to reporting Serious Adverse Incidents ('SAIs').
SAI Reporting as Disciplinary Offence
Failure to report an SAI should be a disciplinary offence.
CEO Responsibility for Investigations
Compliance with investigation procedures should be the personal responsibility of the Trust Chief Executive.
Independent SAI Investigation
The most serious adverse clinical incidents should be investigated by wholly independent investigators (i.e. an investigation unit from outside Northern Ireland) with authority to seize evidence and interview witnesses.
Non-Cooperation as Disciplinary Offence
Failure to co-operate with investigation should be a disciplinary offence.
Separation of Investigation and Litigation
Trust employees who investigate and accident should not be involved with related Trust preparation for inquest or litigation.
Family Involvement in SAI Investigations
Trusts should seek to maximise the involvement of families in SAI investigations and in particular: (i) Trusts should publish a statement of patient and family rights in relation to all …
Multi-Disciplinary Peer Review
Investigations should be subject to multi-disciplinary peer review.
Investigation Team Reconvening
Investigation teams should reconvene after an agreed period to assess both investigation and response.
SAI Learning Informing Clinical Audit
Learning and trends identified in SAI investigations should inform programmes of clinical audit.
Publication of External Investigation Reports
Trusts should publish the reports of all external investigations, subject to considerations of patient confidentiality.
Sharing New Investigation Information
In the event of new information emerging after finalisation of an investigation report or there being a change in conclusion, then the same should be shared promptly with families.
Adverse Incident Communication Training
Clinicians caring for children should be trained specifically in communication with parents following an adverse clinical incident, which training should include communication with grieving parents after a SAI death.
SAI Investigator Training
Training in SAI investigation methods and procedures should be provided to those employed to investigate.
Time for SAI Learning
Clinicians should be afforded time to consider and assimilate learning feedback from SAI investigations and within contracted hours.
Informing Teaching Authorities
Should findings from investigation or review imply inadequacy in current programmes of medical or nursing education then the relevant teaching authority should be informed.
Using Investigations for Training
Information from clinical incident investigations, complaints, performance appraisal, inquests and litigation should be specifically assessed for potential use in training and retraining.
Board Awareness of SAI Reports
Trusts should ensure that all internal reports, reviews and related commentaries touching upon SAI related deaths within the Trust are brought to the immediate attention of every Board member.
Policy on Learning from SAI Deaths
Each Trust should publish policy detailing how it will respond to and learn from SAI related patient deaths.
SAI Deaths in Annual Reports
Each Trust should publish in its Annual Report, details of every SAI related patient death occurring in its care in the preceding year and particularise the learning gained therefrom.
Expand RQIA Remit and Resources
The Department should expand both the remit and resources of the RQIA in order that it might (i) maintain oversight of the SAI process (ii) be strengthened in its capacity …