Encouraging a learning culture by reporting errors

22. When something goes wrong with patient care, it is crucial that it is reported at an early stage so that lessons can be learnt quickly and patients can be protected from harm in the future.

23. Healthcare organisations should have a policy for reporting adverse incidents and near misses, and you must follow your organisation’s policy.28

24. A number of reporting systems and schemes exist around the UK for reporting adverse incidents and near misses.

a. Adverse and patient safety incidents in England and Wales are reported to the National Reporting and Learning System.29

b. You must report suspected adverse drug reactions to the UK-wide Yellow Card Scheme run by the Medicines and Healthcare products Regulatory Agency (MHRA) and the Commission on Human Medicines.30

c. You must report adverse incidents involving medical devices to the UK-wide MHRA reporting system.31

d. Healthcare Improvement Scotland has a national framework,32 which outlines consistent definitions and a standardised approach to adverse incident management across the NHS in Scotland.

e. The procedure for the management and follow-up of serious adverse incidents in Northern Ireland is set out on the Department of Health, Social Services and Public Safety’s website.33

f. In England, general practitioners and other primary medical services must submit all notifications34 directly to the Care Quality Commission (CQC).

25. In addition to contributing to these systems, you should comply with any system for reporting adverse incidents that put patient safety at risk within your organisation (see paragraphs 32–33 on the organisational duty of candour). If your organisation does not have such a system in place, you should speak to your manager and – if necessary – raise a concern in line with our guidance.3536

26. Your organisation should support you to report adverse incidents and near misses routinely. If you do not feel supported to report, and in particular if you are discouraged or prevented from reporting,37 you should raise a concern in line with our guidance.35,36

27. You must not try to prevent colleagues or former colleagues from raising concerns about patient safety.38 If you are in a management role, you must make sure that individuals who raise concerns are protected from unfair criticism or action, including any detriment or dismissal.37

28. You must take part in regular reviews and audits39,40 of the standards and performance of any team you work in, taking steps to resolve any problems. You should also discuss adverse incidents and near misses at your appraisal.41,42