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The purpose of this paper is to determine the prevalence of feedback following adverse clinical incident reporting among trainee doctors in obstetrics and gynaecology within the Northwestern Deanery of England.

An anonymous questionnaire was circulated among the Specialist Registrar trainees within the specialty attending a regional teaching session. The questionnaire was analysed.

There were 50 responses, of those 45 (90 per cent) had been involved in an adverse clinical incident; 44 had submitted an incident form related to the incident. Three had submitted incident forms without being involved in an adverse incident. Most (80 per cent) had submitted an incident form as well as a related statement. Feedback was available to 23 (51 per cent) of those involved in adverse incidents. More of the senior trainees received feedback than the junior ones. A lecture on clinical incident reporting was available to only 35(70 per cent) of the respondents on the hospital induction day at their latest clinical placement.

This study is limited to adverse clinical incident reporting among the trainees in a single specialty within one deanery in UK; hence the small numbers.

This study demonstrates the presence of awareness regarding adverse incident reporting among the trainees in a high‐risk specialty. It also shows the suboptimal rate of feedback following adverse incident reporting, which does not encourage a learning environment. It is suggested that a lecture should be dedicated to incident reporting at the junior doctors' induction day programme in every hospital.

This paper highlights the lack of adequate feedback following adverse clinical incident reporting.

The purpose of this study is to determine the effectiveness of incident reporting within the Department of Gynaecology at Trafford General Hospital.

A list of all reported clinical incidents in relation to gynaecology at the Trafford General Hospital over a period of two years (January 2005 to December 2006) was obtained. The complaints and claims related to gynaecology were also obtained for the same time period. All complaints and claims were correlated with the reported adverse incidents.

Of the reported 111 adverse incidents, none resulted in either complaint or claim. None of the complaints resulted in claims but there was no corresponding incident reporting. All the claims were directly related to surgical procedures but no incident reporting was done either. The nursing staff filled in all the 111 adverse incident forms.

This study is only limited to adverse incidents in gynaecology over a short period of time (two years) at a District General Hospital.

This study demonstrates the need to stress the importance of incident reporting to the doctors. It is suggested that a session be dedicated to incident reporting as a part of in‐house training for medical staff of all grades.

This paper highlights the need to impress on the medical staff about the importance of adverse clinical incident reporting.

This paper outlines the process and context in which the Clinical Risk Modification Project at Sligo Hospital, Ireland was established and focuses on the issues encountered from conception to implementation. The project is based in the emergency and orthopaedic departments and is of two years duration. The stated aim of this project is to design and test a framework incorporating the core components of a workable Clinical Risk Modification programme in the context of an Irish general hospital. This involved making an explicit commitment to the principles of a learning organisation including blame free risk reporting, providing education and awareness training to promote understanding of clinical risk management locally, and developing a clinical incident/near miss reporting system to address clinical risk in both a proactive and reactive way.

The use of violence risk assessment measures within intellectual disabilities (ID) services is now the norm and a growing target for research. The purpose of this paper is to examine the clinical utility of the historical and clinical factors of the HCR-20 in predicting violence.

The study took place within a national low secure service for adults with ID examining all completed admissions over a six-year period, (N=22). Clinical records covering the first three months of admission were examined along with historical reports and incident data recorded at three, six, nine and 12 months admission using the Modified Overt Aggression Scale (MOAS).

Significant positive relationship between Historical score and total number of incidents was established. Patients with challenging behaviour less likely to have a previous history of violence, and more likely to be older at first violent incident than patients without challenging behaviour. Incidents involving patients with autism were less severe and those with no additional psychiatric diagnosis were significantly more likely to have substance misuse problems than those with a diagnosis.

The study found the Historical section was predictive of violent incidents and whilst the study is too small to draw any firm conclusions, the significant positive relationship between the Historical Score and number of incidents for those without additional diagnosis needs to be investigated further as well as the potential positive clinical impact of using the HCR-20 in routine clinical practice.

Error reporting by healthcare staff, patient-derived complaints and patient-derived medico-legal claims are three separate processes present in most healthcare systems. It is generally assumed that all relate to the same cases. Given the high costs associated with these processes and strong desire to maximise quality and standards, the purpose of this paper is to see whether it was indeed the case that most complaints and claims related to medical errors and the relative resource allocation to each group.

Electronic databases for clinical error recording, patient complaints and medico-legal claims in a large NHS healthcare provider organisation were reviewed and case overlap analysed.

Most complaints and medico-legal claims do not associate with a prior clinical error. Disproportionate resource is required for a small number of complaints and the medico-legal claims process. Most complaints and claims are not upheld.

The authors have only looked at data from one healthcare provider and for one period. It would be useful to analyse other healthcare organisations over a longer time period. The authors were unable to access data on secondary staffing costs, which would have been informative. As the medico-legal process can go on for many years, the authors do not know the ultimate outcomes for all cases. The authors also do not know how many medico-legal cases were settled out of court pragmatically to minimise costs.

Staff error reporting systems and patient advisory services seem to be efficient and working well. However, the broader complaints and claims process is costing considerable time and money, yet may not be useful in driving up standards. System changes to maximise helpful complaints and claims, from a quality and standards perspective, and minimise unhelpful ones are recommended.

This study provides important data on the lack of overlap between errors, complaints and claims cases.

The current national patient safety strategy for the National Health Service (NHS) in England states that actions need to be taken to support the development of a patient safety culture. This includes that local systems should seek to understand staff perceptions of the fairness and effectiveness of serious incident management. This study aims to explore the perspectives of patient safety professionals about what works well and what could be done better to support a patient safety culture at the level of Trust strategy and serious incident governance.

A total of 15 professionals with a role in serious incident management, from five mental health trusts in England, were interviewed using a semi-structured interview guide. Thematic analysis and qualitative description were used to analyse the data.

Participants felt that actions to support a patient safety culture were challenging and required long-term and clinical commitment. Broadening the scope of serious incident investigations was felt to be one way to better understand patient safety culture issues. Organisational influences during the serious incident management process were highlighted, informing approaches to maximise the fairness and objectivity of investigation findings.

The findings of this study offer original insights that the NHS safety system can use to facilitate progression of the patient safety culture agenda. In particular, local mental health trusts could consider the findings in the context of their current strategic objectives related to patient safety culture and operational delivery of serious incident management frameworks.

To investigate the association between implementation of clinical governance and patient safety.

A pre-post study was conducted in an Australian health service following the implementation of clinical governance systems (CGS) in the inpatient wards in 2016. Health service audit data from 2017 on CGS implementation and the rate of adverse patient safety events (PSE) for 2015 (pre-implementation) and 2017 (post-implementation), across 45 wards in six hospitals were collected. CGS examined compliance with 108 variables, based on the Australian National Safety and Quality Health Service standards. Patient safety was measured as PSE per 100 bed days. Data were analysed using odds ratios to explore the association between patient safety and CGS percentage compliance score.

There was no change in PSE between 2015 and 2017 (MD 0.04 events/100 bed days, 95% CI -0.11 to 0.21). There were higher odds that wards with a CGS score >90% reported reduced PSE, compared to wards with lower compliance. The domains of leadership and culture, risk management and clinical practice had the strongest association with the reduction in PSE.

Given that wards with a CGS score >90% showed increased odds of reduced PSE health service boards need to put in place strategies that engage frontline managers and staff to facilitate full implementation of clinical governance systems for patient safety.

The findings provide evidence that implementation of all facets of CGS in a large public health service is associated with improved patient safety.

The standard of health care in prisons should be equivalent to that provided in the community. Prison populations are multiply disadvantaged and primary health care practitioners in prisons routinely face organisational and ethical challenges which are rare in community‐based general practice. This raises the question of whether doctors working in prisons consider they would benefit from additional clinical skills or training, the range of prison‐specific competencies they consider important and what they would like to see included in induction programmes. Through a series of semi‐structured, faceto‐face interviews with doctors and health care managers working in prisons, this study sought to identify views on the training needs for doctors working in prisons. Practitioners demonstrated that induction processes were varied and fragmented and that delivering primary care in prisons raised additional clinical and organisational challenges. Relationships with prisoner patients were generally good. Few ethical issues were raised by this small sample, with the exception of confidentiality. However, aspirations towards equivalence were tempered by tensions between custodial needs and clinical requirements, and more research should be directed to the ways practitioners negotiate this interface. Induction programmes should ensure that all practitioners receive practical and ethical guidance to help them address these tensions.

This paper aims to discuss and present research findings from a proof of concept pilot, set up to test whether a teaching intervention which incorporated a dual reporting and learning approach from adverse incidents, could contribute towards individual and organisational approaches to patient safety.

The study formed part of a series of six iterative action research cycles involving the collaboration of students (all National Health Service (NHS) staff) in the co‐creation of knowledge and materials relating to understanding and learning from adverse incidents. This fifth qualitative study involved (n=20) anaesthetists who participated in a two phase teaching intervention (n=20 first phase, n=10 second phase) which was premised on transformative learning, value placed on learning from adverse incidents and reframing the learning experience.

An evaluation of the teaching intervention demonstrated that how students learned from adverse incidents, in addition to being provided with opportunities to transform negative experiences through re‐framing learning, was significant in breaking out of practices which had become routine; propositional knowledge on learning from adverse incidents, along with the provision of a safe learning environment in which to challenge assumptions about learning from adverse incidents, were significant factors in the re‐framing process. The testing of a simulated dual learning/reporting system was indicated as a useful mechanism with which to reinforce a positive learning culture, to report and learn from adverse incidents and to introduce new approaches which might otherwise have been lost.

The use of a “re‐framed learning approach” and identification of additional leverage points (values placed on learning and effects of dual reporting and learning) will be of significant worth to those working in the field of individual and organisational learning generally, and of value specifically to those whose concern is the need to learn from adverse incidents.

This paper contributes to individual and organisational learning by looking at a specific part of the learning system associated specifically with adverse incidents.

The paper aims to appraise professional practice in safeguarding vulnerable adults. It will examine the mechanisms in place and discuss how future policy will affect multi‐agency working in this field.

The paper examines recent consultations, policy development, inspectorate reports and legal guidance surrounding the issue of safeguarding adults in England and Wales, and suggests ways in which inter‐agency working can be strengthened.

Safeguarding systems need to be timely, rigorous and transparent to increase levels of public confidence and to ensure that the people who are at most risk of being abused are safe when accessing public services. The concept of safeguarding adults is increasingly being integrated into government policy and there are many successful examples of safeguarding partnership working in England and Wales. However, there are also substantial barriers that hinder organisations from working together effectively, such as different cultures, practices and ideologies.

The paper explores the fact that there needs to be clarification of roles and responsibilities and integration of processes, and acceptance of true multi‐agency working. There is a danger that instead of providing extra protection for adults at risk, multiple routes will result in a lack of co‐ordination.