Appendix A - Learning from local events and experiences

How lessons can be learned	What lessons	Benefits of sharing	Who is responsible for sharing	How will lessons be shared
Highlighting patient safety trends	Improved understanding of hot spots and recurring themes	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 incidents	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 complaints	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 Team	Quarterly reports Annual report
Analysis of individual claims	Improved understanding of source and reasons for claims	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 errors	Improved understanding of source and reasons for errors	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 Team	Via Trust Wide Patient Experience and Carer Group Quarterly reports
Analysis of aggregated information	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 improvement	Sharing good practice – to avoid “reinventing the wheel”. Improved clinical practice.	Clinical Audit and Service Evaluation Group	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 inspections	Compliance with the CQC fundamental standards and lessons learned from inspections/MHA 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 group Compliance pages on I-connect

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