Improving quality and safety in healthcare: learning from incidents

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Case studies on improving incident reporting culture, providing feedback to staff involved in incidents, sharing learning across the organisation and changing practice to prevent recurrence.

Cornwall Partnership NHS Foundation Trust

Case study: Reducing risk of recurrence of medicines incidents by closing the feedback loop PDF, 166.6 KB

Providing feedback to staff involved in a prescribing incident, encouraging private and public reflection and feedback to the trust on how to improve systems and processes.

Oxleas NHS Foundation Trust

Case study: Introducing a rapid improvement process to address safety challenges and improve multidisciplinary work, patient risk assessments and care plans PDF, 110.4 KB

Introducing executive-led intensive improvement support and working closely with-ward level staff, in response to incident and CQC inspection findings, to improve safety standards and working practices in clinical areas.

University Hospitals Bristol NHS Foundation Trust

Case study 1

Case study: Developing a dedicated emergency department checklist to prevent recurrence of serious incidents during overcrowding PDF, 131.9 KB

Following thematic review of incidents resulting from missed deterioration during periods of overcrowding in the emergency department, the trust devised a checklist that helped to ensure patients continued to benefit from good care during periods of high demand.

Case study 2

Case study 2: Sharing learning from incidents through creative, eye-catching design PDF, 181.4 KB

Illustrates how University Hospitals Bristol NHS Foundation Trust created its own internal system of safety alerts, underpinned by creative design.

As a learning organisation, we would be grateful for feedback, as well as suggestions of local good practice that could complement our case studies. Please email any feedback and examples through to nhsi.medicaldirectorate@nhs.net using the subject line 'safety case studies'. 

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