Embedding learning from adverse incidents: a UK based
regional case study
ESHARETURI, C and SERRANT, Laura
<http://orcid.org/0000-0002-9382-9859>
Available from Sheffield Hallam University Research Archive (SHURA) at:
http://shura.shu.ac.uk/14125/
This document is the author deposited version. You are advised to consult the
publisher's version if you wish to cite from it.
Published version
ESHARETURI, C and SERRANT, Laura (2017). Embedding learning from adverse
incidents: a UK based regional case study. International Journal of Health Care
Quality Assurance, 30 (3), 216-223.
Copyright and re-use policy
International Journal of Health Care Quality Assurance
! "
# $ % %& % ' ()* %% " + "' ' "
, )' - , ' , . "
International Journal of Health Care Quality Assurance
! " #$%&' ''()*% + , + +
-. / . " 0
1 " 2 " #$$% **) )3&%
+ , + +
+ ,! + +
! 1 ! 2
4 ! + - 5 " 6 "
" " ! " + 0 ! "
4 6 7 22 2 !
2 " " " 2 +
" 8 4 " 9 " ! ! !
! " 2 + ! " 2
" " ! 7 2 "+
# 8 / ! $ : *#$$ '# : *#$*
9 . ! 2 + ;
! " !+
" 2 " ! "
2 + 2 " 2 " < 2 = 2 =
! +
$ 8 4 2 ! ! "
" < 2 + " ! !
< " + " "
" 2 " " ! +
" " 2 "
2 " " " 2+
% & " 2
2 +
! / > 2 " "> - > - " 2 >
. > " +
-' ? ) *#$@
' ? * / " *#$@
?
(
4 2 " 2 " = 2 ! 2
2 " 2 + 9
! "= " A B
" ! " . " "
Page 1 of 9 International Journal of Health Care Quality Assurance
International Journal of Health Care Quality Assurance
2
" " C . - " " 2
! B/ 7 *#$)C+ 4 2
" " 2 "
. B. C 2
! B 2 *##&C+ ! " " 7 !
22 2 2 B1 *#$#C+ < ! 2
" " *
. 1 " D $+$
2 B . 0 4 *#$@C+
) *
/ < " " B ! *##)>
*##3> . *#$#C "A 2
. " B- ! *##(> 5 2 *#$)C+
. - " " 2 ! *##'
2 " " 2
B1 2 ; *##@C+ ! ! 2 2
!= " B1 *#$#C+
2 2 2 " 2
B1 *#$#C> + + 2 ! " 2
22 2 + <
2 2 1 2 " 6 D ! 8
" " " < 2 +
- ! " 2 = " " ! +
! ! ! " " 2 +
7 2 ! 2 " " 2
+
4 ! / " *#$* 0 *#$' 7
2 B- /C . 4
" $* 2 B: *#$$=: *#$*C+ !
! " > ! "
2 " ! + < *
! 2 = 2 + 4
! 2 !
2 " * + 4 !
" 2 " "
+ ;! " 6 ! ! 2 2 2
" 2 " + 4 2 2 2
< 2 = +
! 2 1 2 " +
#
/ " 8 7 < 2 " 2 " 2
" ! 7 "
2 2 + /
! $ : *#$$ '# : *#$* 2 " 4 8 / = > =
2 > = 2 ! + ; - /
2 ! 2 " "
Page 2 of 9 International Journal of Health Care Quality Assurance
International Journal of Health Care Quality Assurance
! ! " 2 8 B C - / < ! " 2
2 "> B C 2 - / " "
2> B C ! " 2 2 2
< + 4 - / ! < B " C B2 C
- / B 2 " *% %( C+ / "
2 2 ! ! " 2 +
2 " " 2 ! " < B/ 7 $C 2 !=
2 = ! ! " 2 2 + = 2 =
! ! 2 " - / 2
" 2 + 4 ! !
" 2 + " !
" 2 ! ! " " !
! " +
$
7 " " " " E 6 !
8
6 " 2 + F
2 > !
B . ? G C+
- E 6 !
8
2 " " "
2 ! " "
B 5 " C+
4 "" 2 7 2 " " <
2 " +
" 2 " !
! " 2 2
2 "+ ! E 2 6 ! " " <
2 + - 2 " "
7 ! " 7 8
4 2 7 2 < 2 !
" 2 B C+
E1 6 ! ! 2 " "
" " < 2 8
! 6 " H I " ! 6 " "
H 7 2 I " ! 6 " 2 2
" ! " D
" = " B 5
" C+
Page 3 of 9 International Journal of Health Care Quality Assurance
International Journal of Health Care Quality Assurance
4
1 2 " 2
2 " ! 2 2 " " 6 D
2 " =" " " + 2 E "6 !
" 8
1 2 " ! "
2 "" " "
2 B 5 0 C+
4! 2 " " = "
+ 1 " ! "
" ! " !
"" ! 2 ! " 6 +
1 " 2 " " 26 +
" "
< " " !
" "
7 +
2 " 2 " !
2 " " + " "
< ! ! " 2 ! < < 6
" 8
0 " < !
" 2 2 ! B 5 0 C+
1 " ! " 2 6 2 7
! 8
/ ! " " " " 2 " 2 ! !
2 " " 2 2 ! ! 2 ! " "
! " B C+
2 " " < + 4
2 2 2 2 " " - / 2
! " " " 7
- / " ! + /
2 6 !
< ! ! " " " 2
7 +
/ 22 2 4 ! ! 4 /
+ 4 / " 2 ! "
" < + 4
22 " " " 2 ! "
+ 4 ! " 2 " 7 2
" 2 2 " 2
Page 4 of 9 International Journal of Health Care Quality Assurance
International Journal of Health Care Quality Assurance
" + = " " 2
< " 2
! 6 + " 22
! = ! "" 2
" 2
7 "" 2 + ! 2 !
2 " " 2 7 " " 2
! 8
! 6 " 2 2 2
2 " " "
2 " ! 6 " ! " " " " !
< B 5 " C+
4 ! " " "
"" 2 < ! 2
" " " " + 4 < " !
2 " " + 1 !
" " 22 ! "
2 " ! !
2 " " 22 6 2 " "
+ / D 2 ! ! 2 7
! 22 =" " " !
! " 8
! 22 " !
! 2 " ! < <
2 2 22 6 " 2 !
6 B . ? G C+
; 22 6 2 2 "
22 8
! =" " " 2 2 + 4
2 " > 22 2 2 "
! 2 2 2 " " 6 B
C+
22 " " ! " " 2 ! "
" ! ! 2 ! 22
2 =" " " +
1 ! ! 2 !
" ! < 7 8
! ! " 2 " " 2
2 " 22 !
2 2 2 2 2 6 6
" + "
Page 5 of 9 International Journal of Health Care Quality Assurance
International Journal of Health Care Quality Assurance
6
" ! ! 2 ! ! "
J 2 2 " " B
C+
- ! 2 2 "
! " 8
/ H I 2 " " 2 ! 2 "
" ! " 2 2 ! <
! ! 6 " 2 2 " 2 + !
B 5 0 C+
2 ! " . 2 " "
" "
2 + " 2
! ! 2 "
" 2 ! 8
4 ! ! " " 2
2 " 2 " 2 ! ! " !
" B / C+
! ! 2 " " " " 2
+ ; ! 8
! 22 22 + 4
! < "
. - " " 2 " 7 2
2 H.- 4 I+ / ! 2 "
! 2 + 2 "
7 " B- " C+
1 ! ! " " 2 "
! 8
" " 2+ ! 6 " " "
H " I 2 < ! ! "
" ! " "
2 " 2
" BG C+
- " 2 !
2 " ! " 8
! K / ! " " K
" 2 " 2 " ! " " 2 !
! 6 " " K
2 " " " "K
22 " " < B- "
- 5 C+
Page 6 of 9 International Journal of Health Care Quality Assurance
International Journal of Health Care Quality Assurance
/ " " " 2 " " 2
" 8
< ! J ! !
" 2 " 22
! ! 6 "
B- " - 5 C+
7 " 2 " " 2 "
+ 4 7 ! " 2 +
/ " " " " ! "
! ! 22 + 1
2 " "
22
" + 1
" " ! ! ! !
2 " 2 7 < + "
" " " ! 2 " 2 + 1
2 2
"+ 22 2 2
2 7 2 2
! " ! "
7 " "+
22 ! " " 2
+ 2 " 22
+ 1 ! ! " " 2
2 ! "
" < !
2 2 + "
" 2 2 + 2 !
< 2 " !
22 +
1 ! 2
2 " " " 2 2 + 0
< ! 2 22
22 2 2 ! 2+ 22 2 "
2 < 2 D "
2+ 4 2 ! ! ! 7 "
! " + 0
" 2 " " " 2
< " + 4 2 "
22 ! 2 2 "
" +
Page 7 of 9 International Journal of Health Care Quality Assurance
International Journal of Health Care Quality Assurance
8 '
/ 7 + + / + B*#$)C E/ . - " "
2 " 1 ! K6 ! "
# $ " L + $) . + ' + '@)='@(+
. 0 4 + B*#$@C E 2 6
M 8AA!!!+ + + A = A < = = A'@%= 2 = = =
= N *#$@+
2 B*##&C E " . 8 2 2 "
" ! 2 2 6 M 8AA! + +" + A
*#$'#$#&$#)')%A 8AA!!!+ +" + A A A A
/ 5 A ! A O%3$@)*&N *#$@+
5 2 + :+ / + 9 + 1 2 + 5 + B*#$)C E
2 2 " 2 K6 %
& ' ( ) L + *( . +( + (@%=(&$+
/+ F " 4+ /+ 9+ + /+ 9 :+ + +
4 2 -+ 5+ B*##3C E4 "
< 8 2 . - "
" 2+6 ( & ' L + $( . +$ + )=$#+
. + :+ + :+ B*#$#C E "
6 < 2 2 +6 %
# L + @ . +% + *%&=)#+
- ! + L " + ; ! + /+ 2 :+ B*##(C E
"8 ! " 2 ! " +6 % & '
( ) L + *$ . +% + '(#='(%+
1 + B*#$#C E0 2 - " ? . 4
" K6 % & " # L + $) . +$
+ &)=&(+
1 2 + 9+ ; + + B*##@C E4 2 . - "
" 2 " 1 *##$?*##)6+ % )
L + $(% . +$ + @)=@(+
+ 2 " " 2 - / 8 9 2 !
,
1 " 2 - /K
1 " K ! K
1 "" " 2 - / K 1 "
! " 2 K
1 22 " 2
K
1 22 2 " " 2
K ! K ! ! K
-! - / 2 < 2 K
1 2 ! " 2 - /
2 K
1 2 " D K 2 8
! ! K
! K
Page 8 of 9 International Journal of Health Care Quality Assurance
International Journal of Health Care Quality Assurance
1 ! ! " 2
- / K
1 2 22 2
2 " 2 K
! 2 " " " " 2
K
" ! ! K
Page 9 of 9 International Journal of Health Care Quality Assurance