Improvement needed on NHS incident cases

Calum Campbell
Calum Campbell

A report has called on NHS Borders to improve the way it deals with “significant adverse events” following a review of its policies and procedures.

The Healthcare Improvement Scotland report makes 14 recommendations to the board.

Calum Campbell

Calum Campbell

In the 18 months to March, 118 incidents were graded as “significant adverse events” – those which could have, or did, result in the unnecessary serious harm or death of a patient, employee, visitor or member of the public.

The review of the health board’s policies was carried out as part of a Scotland-wide review of the way the NHS deals with serious incidents.

In the Borders, it discovered that some staff were not even clear on what was categorised as a “significant adverse event” and found there was not a consistent approach to engaging with patients, families and carers after an incident. Following a report on NHS Ayrshire and Arran’s serious incident policies, NHS Borders implemented new procedures, but these were at an early stage when the review took place, meaning existing policies were examined.

However, the report praised the board for implementing the changes, the support available to staff, and the culture of reporting incidents of among employees.

But issues were raised about the lack of feedback to staff following incident reviews, and the fact that some reviews did not meet the required timescales.

Between October 2011 and March, 91 clinical incidents were investigated – 24 per cent due to slips, trips and falls. A total of 27 general safety “events” were reported, all relating to “aggression, violence or personal safety”.

Calum Campbell, NHS Borders chief executive, said: “The report highlighted that we already have a good culture of incident reporting and a high level of professional support from our clinical governance team. This gives us a solid platform to build on and develop our systems further.

“Improving health care is an ongoing process and we welcome the recommendations in the report, which will provide the focus for our action plan and further development.”