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Shine a light on.... Adverse Incident Investigations for Boards

It is widely recognised that an effective board is one of the fundamental drivers of quality improvement and patient safety.

The Monitor Guidance for Boards of NHS Provider organisations advocates that boards assure themselves that ‘patient safety incidents are being reported and dealt with correctly and escalated to the Board appropriately’.  It stresses the importance of a robust investigation to identify any systems failures and maximise the learning opportunity.


Within Northern Ireland, The Inquiry into Hyponatremia related Deaths (The Inquiry into Hyponatraemia-related Deaths, 2018) identifies the critical role of Board members in overseeing and improving the quality and safety of services provided to patients and service users.
In particular, the Inquiry into Hyponatremia related Deaths (2018) has placed a focus placed on the responsibility of the Board to hold the organisation to account for the quality and robustness of the investigation of serious adverse incident-related deaths and where appropriate, how this information is being used to implement effective and sustainable changes which will reduce the chance of future occurrence.

The Shine a Light on Adverse Incident Investigation Programme has been developed to enhance the understanding of Board members in of the serious adverse incident review process and its contribution to the improvement of quality and safety of care.
Specifically, the training will allow Board members to:

  • Gain an understanding of the System Analysis approach to incident investigation, where the focus moves from blaming individuals to seeking to identify the weaknesses or deficiencies in the system which may have caused the adverse event to occur.

  • Understand how a robust investigation facilitates the identification of factors which contributed to the adverse incident, allowing actions to reduce the chance of future occurrence

  • Understand the concept of Open Disclosure and its impact on engagement with patients, service users and their families during adverse incident investigations.

  • Gain an understanding of organisational mechanisms to assess how effective recommendations have been in preventing or minimising recurrence.

1-Day Workshop Format

Supported by CLS Build App

Programme Resource Website

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