Management of adverse events: review report: NHS Borders

Document type
Corporate author(s)
Scotland. Healthcare Improvement Scotland
Healthcare Improvement Scotland
Date of publication
30 April 2013
Health Services
Social welfare
Material type

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This review of NHS Borders’ governance arrangements and processes for managing adverse events involved an analysis of evidence provided by the NHS board and a visit to NHS Borders on Tuesday 12 March 2013.

The following areas of good practice within NHS Borders were noted: 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 a commitment, in response to the Ayrshire & Arran recommendations, through the development and implementation of an improvement plan to introduce a single system approach to adverse event management.

However, the review identified challenges in the management of significant adverse events. These include patient, family and staff engagement; consistent implementation of methodologies and decision-making; and the sharing of wider learning. Recommendations for improvement are therefore given.