Significant Adverse Event Reviews: Information for Staff

Significant adverse event reviews: Information for staff

We know that the NHS in Scotland already provides excellent, care but we also know that sometimes things do go wrong. As healthcare professionals we are not infallible. Being involved in an adverse event can be a stressful experience, especially after a very serious event when someone has been seriously injured or has died.

It is important that you are supported following an adverse event and your manager, supervisor or clinical governance support team will have information available for you. Everyone reacts differently to stressful or upsetting situations. You may be feeling fear, guilt, sadness, or anger and it’s important to talk about your feelings with people you can trust. Common physical and mental reactions include tiredness, poor concentration, anxiety, disturbed sleep and nausea. You may also wish to access support from occupational health, chaplaincy services, employee assistance programme, staff counselling. Please speak to your manager for more information.

What is a significant adverse event review?

A significant adverse event review is a process used following an adverse event to determine what happened, how it happened, why it happened, and whether there are learning points for the service or wider organisation. The aim is to:

establish the background and sequence of events that led up to the adverse event
identify underlying contributing factors in management and organisational systems
identify lessons learned, develop recommendations and implement improvements that would prevent s similar adverse event occurring in the future, and
communicate any findings and recommendations across the organisation and with those individuals directly affected or involved.

It is important to note that whilst acknowledging the professional responsibility and accountability of all staff and departments involved in the adverse event, it is not the purpose of this process to apportion blame. The aim is to promote a fair and just culture in an atmosphere where an employee can openly discuss errors or omissions, process improvements, and/or system corrections without the fear of reprisal. If the review team considers that there are any issues about the performance of an individual member of staff, this should be referred to the appropriate line manager and should not be part of the review.

How long after the adverse event will a review be carried out?

This depends largely onthe severity of the adverse event, and the size and availability of the review team. Ideally it should be within three months of the date of the event.Once a SAER has been confirmed it will be about six - eight weeks before the actual date of the review meeting to allow for time off on duty rosters.

Why have I been asked to attend this review?

You were directly involved in the adverse event and your recollection and views are vital to this process and will assist in reviewing the care provided and to identify any learning or service improvements.

Should I inform my manager that I have been invited to this review?

Your manager should already be aware that you are involved. However, you may wish to discuss this with them as you may feel you need support and you will need to be released from duty to attend the review.

Who is involved in the review?

A lead director or senior manager should be appointed to ensure a thorough and appropriate review is undertaken.A review team will be established with a lead reviewer appointed and review team members will be multidisciplinary and include a professional with experience relevant to the event being reviewed. The team should be sufficiently removed from the event and have no conflict of interest to be able to provide an objective view.Staff side or partnership representatives can be involved throughout the process. Any key member of staff and management both internal and external who were involved in the provision of care to the patient or who manage the service can be asked to be involved.

A member of the clinical governance team may be at the meeting to provide support.

Each person will be asked to introduce themselves at the start of the meeting and indicate their reason for attending.A record of the discussion will be made and used in the collation of the report. Once the report is finalised the record of the discussion will be destroyed.

What happens during a review?

The review team gathers information to understand what has happened in a number of ways:

speaking to staff involved
speaking to the patient, family or carers
speaking to the managers of the service
looking at the clinical notes and records
asking experts or specialists for input, and
looking at relevant guidelines and policies.

The team will review all the information and a report on the findings will be written.The report will include any improvements that need to be made to the service.

Where will the review be held?

You will be informed of the date and venue of the review once this is confirmed. Ideally, this will be in a central location to allow minimal travel time for those involved in the review.

Can I bring anyone with me?

You may wish to bring a colleague, your manager, supervisor or a staff side or partnership representative for support.Please inform the review team if you are bringing someone with you.Please note that this person must also indicate at the beginning of the review meeting their purpose for attending.

Can I make notes and bring them along?

Yes, that may be beneficial for you, but remember that these must remain confidential.

Will the patient, patient’s family or carers attend the review?

We want patients, families and carers to be involved in the process as they may have a valuable insight into what happened. A member of the review team will contact them to discuss the process, the timescales and the different ways they can be involved if they want to.For example, they could provide information in writing, or speak to a member of the review team either on the phone or attend a meeting.

Will the patient, family or carer receive a copy of the review report?

It is routine practice that acopy of the review report will be shared with the patient, family members or carers.

How long will the review meeting last?

The meeting lasts approximately two hours.

How and when will I know the outcome?

The approximate timescale for the entire process from the adverse event to the final report should be approximately three months. During this time, a draft report will be collated and sent out to the review team and attendees for comment and approval on factual accuracy. It is essential that you reply with any comments or confirmation of approval by the target date.This will ensure accuracy of the final report.

Once the report has been finalised and approved through our local governance structures,you will receive a copy. However, any urgent actions identified as an outcome of the review must be taken forward immediately. Please be advised that draft reports are highly confidential and not for onward distribution or discussion with persons not directly involved in the review.

Please notecopies of the final report may also be shared with Healthcare Improvement Scotland, the Mental Welfare Commission for Scotland and the Procurator Fiscal as appropriate.

What happens next?

The aim of the review process is to identify lessons learned, develop recommendations and implement improvements that will prevent similar adverse events occurring in the future.An improvement plan will be developed and implemented to address the recommendations and ensure that lessons are learnt and systems and processes improved.You should be involved in the development and implementation of the improvements and your manager should support you with this.

Who can I contact for further information or support?

You may wish to discuss any questions or concerns you have your manager, supervisor or staff side representative.The Central Support Team will also be happy to discuss any concerns with you. Extension numberxxxxxxx

Practical guidance for coping

Recognise that healthcare is complex and things can go wrong – we are not infallible and despite best efforts errors happen.
Expect the adverse event to bother you – remember your response is temporary and you are having a normal response to an abnormal event.Make a conscious effort to work through it.
Realise that others around you may be under stress too – if others were involved help them too, share your feelings. Talk to friends orcolleagues about your experience – this can help reduce feelings of isolation and stress.
Participate in debrief sessions – where it is not deemed mandatory to attend, it is recognised as a valuable tool in supporting staff.
Ensure you are involved, in and kept informed of, the adverse event review process – it is important to contribute to the review and provide insight into preventing recurrence and identify lessons and improvements.
Take time to relax – relaxation techniques can be helpful in dealing with stress and taking time to recover is essential.
Look after yourself – getting enough sleep is important, especially now.If you have trouble sleeping for more than a week contact your GP.Get some exercise – a brisk walk is good for the body and can help combat stress.Maintain a good diet – a healthy diet can counter the impact of stress, boosting the immune system and lowering blood pressure.
Follow a structured schedule – accept you are not capable of doing all things all the time.Be flexible and remember you are healing.Keep life as normal as possible.
Spend time with family and friends – don’t isolate yourself and take time for things you enjoy.
Learn about post traumatic stress – this will help recognise the symptoms and feeling you are experiencing and whether additional intervention is required.
Contact your G, Employee Assistance Programme or Occupational Health if you think you’re not recovering from the event.

Things to avoid

Drinking alcohol excessively.
Staying away from work unnecessarily.
Withdrawing from others or reducing leisure activities.
Using legal or illegal substances to numb consequences.
Having an unrealistic expectations for recovery.
Being too hard on yourself.
Making any major or life changing decisions.

Seeking medical advice

You should seek medical advice if:

you have trouble sleeping for more than a week
your response to the event is too intense or lasting too long
your experiencing physical symptoms to reminders of the event (for example racing heart, nausea, sweating)
you’re experiencing symptoms associated with depression or suicidal feelings
you’re unable to return to work
your response to the event is impacting on your private life and your ability to cope generally with normal activities.