Healthcare Improvement Scotland (HIS)
Monday, 18 August, 2014

Note: The adverse events national framework aims to support NHS boards to standardise processes for managing adverse events across NHSScotland to enable learning and improvement.

This paper presents a refresh of the NPSA Being Open Framework (2009) to support a standardised approach to communicating and engaging with patients, families and carers when an adverse event occurs. The standard approach would apply across all care settings within NHSScotland.

This paper aims to facilitate further engagement and discussion ahead of publishing as guidance with the refreshed adverse events framework later in 2014.

It is not our intention to publish individual consultation responses. Any requests for detailed information on the consultation responses will be responded to in line with the Freedom of Information (Scotland) Act 2002.

BACKGROUND

NHSScotland is committed to delivering high quality healthcare for the people of Scotland. The national approach to learning from adverse events aims to support everyone in NHSScotland effectively manage adverse events, to learn from them, and allow best practice to be actively promoted across Scotland in order that we can continually improve the safety of our healthcare system for everyone.

Open and effective communication with patients, and their family and carers, should begin at the start of their care and continue throughout all the care they receive. This should be no different when an adverse event occurs. Being open when things go wrong is key to the partnership between patients and those who care for them.

Openness about what happened and discussing adverse events promptly, fully and compassionately can help patients and staff cope better with the after-effects of adverse events.

Being open involves:

  • Acknowledging, apologising and explaining when things go wrong
  • If appropriate, conducting a thorough review into the adverse event which involves patients, their families and carers, and aims to identify lessons that will support improvements and help prevent the adverse event being repeated
  • Providing proportionate support for those involved to address any physical and/or psychological consequences of what happened.

We are committed to an open and honest approach and fully endorse the principles outlined in the National Patient Safety Agency’s (NPSA) Being Open Framework 2009:

  • Acknowledgement
  • Truthfulness, timeliness and clarity of communication
  • Apology
  • Recognising patient and carer expectations
  • Culture and professional support
  • Risk management and systems improvement
  • Multidisciplinary responsibility
  • Clinical governance
  • Confidentiality
  • Continuity of care

This document provides guidance for all staff to support openness with patients, their families and carers following an adverse event. As part of our work to support implementation of these principles, NHS Lothian and the NHS National Waiting Times Centre are undertaking a year long pilot project to:

  • test opportunities for application of the principles by establishing a robust process for engaging patients/ families more fully and reliably in adverse events
  • establish an improved culture of openness by developing mechanisms for communicating more actively with patients and their families and to ensure staff are supported when adverse events happen
  • inform discussions nationally on the scalability of a training package across boards in Scotland and the infrastructure required at a local and national level.

The learning and outcomes from the pilot will be shared over the next 12 months and we will share good practice that is identified in other board areas. This document will be updated and re-issued accordingly.

Senior managers and Board Directors should ensure the infrastructure is in place to support an open and just culture where the overall approach expected within the organisation is one of help and support rather than blame and recrimination, where it is safe to report adverse events from which lessons can be learned and patient safety improved.