Improvements need to be made in the way NHS Borders handles serious incidents says Healthcare Improvement Scotland.
Following a visit to the region earlier this year the national inspection body concluded that there is a good culture in NHS Borders when it comes to reporting incidents but there is work to do when it comes to engaging with family and staff when incidents are being investigated.
A total of 14 issues that need tackled were highlighted in the inspectors’ report.
NHS Borders chief executive Calum Campbell said the report had been a “valuable review” of the systems already in place and the work done to comply with the HIS recommendations.
“The report highlighted that we already have a positive and open culture of incident reporting and a high level of professional support from our clinical governance team,” he said.
“This gives us a solid platform to build on and develop our systems further.
“Improving health care is an ongoing process and we welcome the recommendations in the report which will provide the focus for our action plan and further development.”
Inspectors highlighted areas of good practice in NHS Borders: a good culture for reporting incidents across the NHS board; comprehensive support provided by the clinical governance and quality team and in particular, the clinical risk facilitator; good non-executive director engagement; and commitment to an improvement plan to introduce a single system approach to adverse event management.
However, they want to see improvements: in patient, family and staff engagement: a more consistent approach across NHS Borders in dealing with serious incidents; and better sharing of lessons learnt.
Some staff were not clear about what constituted a significant adverse event. These are now defined as “an unexpected or avoidable event that could have resulted, or did result in, unnecessary serious harm or death of a patient, staff, visitor or member of the public or an increase in organisational liabilities”.
Other incidents, such as a significant near miss or an emerging adverse trend, may also be classed as a “significant event” by NHS Borders various executive boards.