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Learning from Serious Incidents: Implementing the CQC Recommendations

Wednesday 7 December 2016
Hallam Conference Centre, London

Learning from Serious Incidents: Implementing the CQC Recommendations

This event has now past, but there may well be news on the event including presentations and quotes from the day at our News pages here, a full list of our forthcoming events is available here.

Follow the conference on Twitter #NHSSeriousIncidents

In July 2016, the Care Quality Commission has called for a step change in the way that serious incidents are investigated and managed in the NHS.

"A service that is safe and well-led will see every serious incident as an opportunity to improve, will support staff to raise concerns within a culture of learning not blaming, and will recognise the need to involve patients and their families when reviewing why and how incidents have occurred.Unfortunately this is not happening everywhere. The needs of patients and their families are not always given priority and the analysis of events sometimes fails to identify the underlying causes that led to the incident in the first place. Investigating serious incidents is a powerful way the NHS can learn from mistakes, reduce or eliminate the risk of harm or death, and improve patient care.” Prof Sir Mike Richards, Chief Inspector of Hospitals at the Care Quality Commission

The Care Quality Commission have identified following five opportunities for improvement for NHS acute trusts:

  1. Prioritising serious incidents that require full investigation and developing alternative methods for managing and learning from other types of incident.
  2. Routinely involving patients and families in investigations.
  3. Engaging and supporting the staff involved in the incident and investigation process.
  4. Using skilled analysis to move the focus of investigation from the acts or omissions of staff, to identifying the underlying causes of the incident.
  5. Using human factors principles to develop solutions that reduce the risk of the same incidents happening again.

This conference focuses on learning from serious incidents: improving the quality of investigations and ensuring lessons are learned and embedded into practice. Through national updates, practical case studies and expert led extended sessions, the conference will provide a practical guide to implementing the five opportunities for improvement as identified through the Care Quality Commission review.

"Safety is our biggest concern. All hospital settings had the largest proportion of inadequate and requires improvement ratings for safety, and our inspections highlighted some poor safety cultures" Care Quality Commission, State of Care 2015/16, October 2016 

We are also running Learning from Serious Incidents: Implementing the CQC Recommendations in Birmingham on Thursday 23 February 2017

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