Out-of-hours anonymised error reports developed in response to Ubani case

An anonymised system for reporting errors in out-of-hours has been developed by the NHS Alliance in response to the Ubani case.

The NHS Alliance said the work was developed in direct response to the Ubani case, in which the death of his patient David Gray was ruled by the coroner as an ‘unlawful killing’.

Developed with a wide range of national partners, the system enables rapid sharing and learning between out-of-hours providers, the NHS Alliance said.

A paper published today, A process for rapid learning: sharing experience when things go wrong in out-of-hours services, reviews the collaborative work of the 10 out-of-hours providers who took part in the pilot over the last year.  

NHS Alliance said the aim was to work with providers who would encourage their staff to report any incident where something had gone wrong and others could learn from what happened to improve patient safety and care.

Rick Stern, urgent care lead for the NHS Alliance said: ‘There is too often a fear that reporting errors will lead to individuals being blamed rather than trying to learn everything we can from mistakes.

Through this initiative we have brought together key players in this field to explore how we can share the learning across organisations and the whole urgent care system.

‘Creating a system that allows people to learn from their mistakes and share the learning with others, rather than being only blamed by what went wrong, is key if we are to improve patients’ safety and out-of-hours services,' Mr Stern said.

NHS Alliance said the scheme had the potential to driving up patient safety across out of hours care by creating a shared approach.

It also helped to shift the way providers thought about incidents giving them ‘cultural permission to admit that occasionally we mess up’.  

The system could join up clinical and corporate governance by offering providers an organisational risk register.

The NHS Alliance said the pilot highlighted the importance of clinical leadership from the top of the organisation on patient safety and the quality of clinical care.

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