A national framework for Scotland is available for reviewing and reporting adverse events. This supports health boards report and review adverse events.
The framework
The scope of the national approach includes all events that could have contributed, or did result in, harm to:
- people
- groups of people
This includes harm to patients and service users, as well as harm to staff. Duty of candour will apply to specific events or incidents that have resulted in death or harm.
The intention is that the national approach can be applied throughout Scotland. This includes:
- acute care and managed community services
- primary care (GP practices, dental practices, community pharmacies and optometrists)
- social care
- employees and independent contractors
- clinical and non-clinical events (including information governance, health and safety at work, adverse publicity and finance)
Reviews and reporting
The framework provides details on reviewing and reporting. Report adverse events (including near misses) using your organisation’s electronic reporting system. You must be trained in the approach your organisation takes.
The types of information you should report in the first instance include:
- the location of where the adverse event occurred
- the date and time of the adverse event
- personal details relating to the person or people involved in the adverse event
- description of the adverse event
- the outcome of the person/people involved (if known at this stage)
- the immediate treatment given to the person or people involved
- any immediate action taken
- any actions taken under duty of candour processes
- any remedial action taken to minimise risk of recurrence of the event
- others who were involved in observing or reporting the adverse event
Data and submission process
The framework states that boards should submit data monthly. This is done by emailing a reporting spreadsheet template to his.adverseevents@nhs.scot. During an NHS multi-board Significant Adverse Event Review (SAERs), the NHS board leading the review will be responsible for notifying us. This notification will include details of:
- the commissioning of the review
- the outcome of the review process
If no SAERs have been commissioned in that month, then a nil report is expected to be returned to HIS.
Notification of a SAER at point of commission alone will not support national learning. It will be a two-stage data submission process to support national learning.
Once a review is complete, boards will be asked to update the initial notification record. They should also submit the outcomes from the SAER process. This will be reported as part of the monthly return.