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Embedding learning from adverse incidents: a UK case study

Cyril Eshareturi (Centre for Health and Social Care Improvement, University of Wolverhampton, Wolverhampton, UK)
Laura Serrant (Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK)

International Journal of Health Care Quality Assurance

ISSN: 0952-6862

Article publication date: 18 April 2017




This paper reports on a regionally based UK study uncovering what has worked well in learning from adverse incidents in hospitals. The purpose of this paper is to review the incident investigation methodology used in identifying strengths or weaknesses and explore the use of a database as a tool to embed learning.


Documentary examination was conducted of all adverse incidents reported between 1 June 2011 and 30 June 2012 by three UK National Health Service hospitals. One root cause analysis report per adverse incident for each individual hospital was sent to an advisory group for a review. Using terms of reference supplied, the advisory group feedback was analysed using an inductive thematic approach. The emergent themes led to the generation of questions which informed seven in-depth semi-structured interviews.


“Time” and “work pressures” were identified as barriers to using adverse incident investigations as tools for quality enhancement. Methodologically, a weakness in approach was that no criteria influenced the techniques which were used in investigating adverse incidents. Regarding the sharing of learning, the use of a database as a tool to embed learning across the region was not supported.

Practical implications

Softer intelligence from adverse incident investigations could be usefully shared between hospitals through a regional forum.


The use of a database as a tool to facilitate the sharing of learning from adverse incidents across the health economy is not supported.



The authors thank all Black Country Trusts staff who contributed to the study. Dr Robin Gutteridge’s support conceptualising and resourcing the study is also acknowledged. Finally, the authors are grateful to the three Trusts’ executive board members who participated in the study for their commitment to improving patient safety by sharing learning from serious incidents.


Eshareturi, C. and Serrant, L. (2017), "Embedding learning from adverse incidents: a UK case study", International Journal of Health Care Quality Assurance, Vol. 30 No. 3, pp. 216-223.



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Copyright © 2017, Emerald Publishing Limited

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