Learning
Recommendations related to learning
Tag overview
recommendation across 8 inquiries
Across 8 inquiries
Tagged Recommendations
Information on common construction errors
It is important that common project errors are not repeated. One helpful step is to ensure health boards undertaking projects have information about such common errors, and that this information …
Serious Adverse Incidents
We recommend that: • The new SAI framework is fully implemented by the Department. There should be regional support for those leading the improvement in the serious incident processes in …
London Fire Brigade to establish lessons learned process
That the London Fire Brigade establish effective standing arrangements for collecting, considering and effectively implementing lessons learned from previous incidents, inquests and investigations. Those arrangements should be as simple as …
Learning from Failures
The Northern Ireland Civil Service should develop a better process to learn from past failures, one that goes beyond the traditional method of revising and circulating internal guidance. Leaders within …
SAI Learning Informing Clinical Audit
Learning and trends identified in SAI investigations should inform programmes of clinical audit.
Time for SAI Learning
Clinicians should be afforded time to consider and assimilate learning feedback from SAI investigations and within contracted hours.
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.
Policy on Learning from SAI Deaths
Each Trust should publish policy detailing how it will respond to and learn from SAI related patient deaths.
Establish partner Trust buddying arrangement
The University Hospitals of Morecambe Bay NHS Foundation Trust should seek to forge links with a partner Trust, so that both can benefit from opportunities for learning, mentoring, secondment, staff …
Review incident investigation structures
The University Hospitals of Morecambe Bay NHS Foundation Trust should review the structures, processes and staff involved in investigating incidents, carrying out root cause analyses, reporting results and disseminating learning …
Duty to report external investigation findings
We recommend that a duty should be placed on all NHS Boards to report openly the findings of any external investigation into clinical services, governance or other aspects of the …
Register external reviews with CQC
We further recommend that all external reviews of suspected service failures be registered with the Care Quality Commission and Monitor, and that the Care Quality Commission develops a system to …
Review of UK IPC reports
Scottish Government (whether through HPS, HIS, the HAI Task Force or otherwise) should as a matter of standard practice ensure that reports published in the United Kingdom and in other …
Health Board review of IPC reports
Health Boards should review such reports to determine what lessons can be learned and what reviews, audits or other measures (interim or otherwise) should be put in place in the …
Lowering barriers
Provider organisations must constantly promote to the public their desire to receive and learn from comments and complaints; constant encouragement should be given to patients and other service users, individually …
Learning and information from complaints
Subject to anonymisation, a summary of each upheld complaint relating to patient care, in terms agreed with the complainant, and the trust's response should be published on its website. In …
Use of information about compliance by regulator from: Media
Any example of a serious incident or avoidable harm should trigger an examination by the Care Quality Commission of how that was addressed by the provider and a requirement for …
Care Quality Commission independence strategy and culture
The Care Quality Commission should undertake a formal evaluation of how it would detect and take action on the warning signs and other events giving cause for concern at the …