Learning from Experience Policy

This policy outlines how the Trust ensures that there is a systematic approach to learning from all types of events and that this is disseminated through a number of different mechanisms.

Publication date:
01 May 2019
Date range:
May 2019 - May 2022

Appendix A - Learning from local events and experiences

How lessons can be
What lessons Benefits of sharing Who is
responsible for
How will lessons
be shared
Highlighting patient
safety trends

Improved understanding
of hot spots and recurring

Reducing risks in other areas.

Enabling resources to be focused on those areas where re occurrence is most likely to reduce risk

Patient Safety Team

Care group governance meetings

SI learning reviews

Quality digest

Analysis of individual
Improved understanding
of local issues and risks
Enabling other areas to understand possible risks and to take preventative action to avoid or minimise future occurrences Local managers
Care Group Leads
Via local and trust wide governance groups
Analysis of individual
Understanding source of
complaints and trends
Giving staff a greater understanding of the implications of their actions and concerns of patients and carers Patient Experience

Quarterly reports

Annual report

Analysis of individual
Improved understanding
of source and reasons for
Giving staff a greater understanding of the implications of their actions and concerns of patients and carers Legal Services Team

Quarterly reports

Annual report

Analysis of medication
Improved understanding
of source and reasons for
Reducing the re-occurrence of medication errors Chief Pharmacist

Quarterly report on medication errors

Quarterly Medication Incidents Newsletter

Analysis of PALs queries Day to day issues that
affect publics, patients
and carers
High volume information provides better understanding
of the day to day issues, which is addressed could
potentially avoid future incident and/or complaints
Patient Experience

Via Trust Wide Patient Experience and Carer Group

Quarterly reports

Analysis of aggregated
Possible links between
incidents, complaints
and claims

Improving staff and management understanding.

Providing “real” information to facilitate and improved decision making across the Trust re. service developments and improvements

Enabling preventative action to be taken.

Improved services.

Deputy Director of
Quality and Safety
Quality Digest
Clinical Audit and Service
Evaluation Projects
Examples of good practice
and where local action has
resulted in service

Sharing good practice – to avoid “reinventing the wheel”.

Improved clinical practice. 

Clinical Audit and
Service Evaluation

Via local/trust wide governance groups

Annual report; Web site; newsletter

Monitoring Central
Alerting System (CAS)
Specific information relating
to equipment used across
the Trust
Avoiding incidents and potential claims by taking prompt action Medical Devices Coordinator E-mail notification to relevant officers
across all sites
CQC unannounced
Compliance with the CQC
fundamental standards and
lessons learned from
monitoring visits
Sharing good practice and highlighting areas for
improvement with all care groups so that the learning can be embedded into practice.
Compliance and
Assurance Manager

Reports to the learning from experience

Compliance pages on I-connect