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Quality Measurement Framework

Safe Care

NHS National Services Scotland ISD Scotland & NHS National Services Scotland

Safe Care

The Quality Strategy proposed that a measure of Adverse Events be developed as a level 1 indicator. Work then began to scope out a definition and data sources for this, and it was proposed that the indicator should focus on serious adverse events. There is no nationally or internationally agreed definition or information source for this.

Following a detailed review of NHS Ayrshire & Arran’s adverse event management in the spring of 2012, the Cabinet Secretary for Health, Wellbeing and Cities Strategy instructed Healthcare Improvement Scotland (HIS) to develop a national approach for the management of and learning from adverse events. HIS have also commenced a programme of reviews to 19 NHS Boards. This is intended to support NHS boards to have a more consistent approach to drive improvement and learn from these events in order to minimise the risk of them happening again.

The paramount importance of prioritising learning from the events has led to the proposal that adverse events measurement should be at “level 3” of the quality measurement framework and not level 1.

This is currently being considered along with other safety measures being developed for the Scottish Patient Safety Programme.

Work that should result in improvement in this indicator

Reductions in adverse events are a key part of the work of the Scottish Patient Safety Programme (SPSP), for example the use of surgical checklists and SBAR communications.

The programme being led by Healthcare Improvement Scotland  will:

  • develop a consistent national approach to identification, investigation, reporting and learning from adverse events based upon national and international evidence and good practice
  • provide public assurance on the appropriate management of adverse events through a programme of NHS board reviews.  

Other national programmes that will result in improvement include the Falls programme and Leading Better Care.


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