Serious incident review
Poll figures show organisations are not doing enough to implement recommendations to prevent serious incidents.
The phrase “lessons will be learned” is now firmly part of modern management speak in all sectors, usually deployed after a heartfelt apology and an acceptance of serious incident review recommendations. Whilst these words will be genuine at the time, Verita’s investigations and experience over the past 15 years show time and time again that organisations are not doing enough to follow-up, to learn from failings internally or across sectors.
A Twitter poll we ran this month asked the question: does your organisation have robust systems in place to implement recommendations from serious incidents?
Of the 1,500 individuals who responded, over a third (37%) said ‘not at all’. A further 38% answered either ‘not a great deal’ or ‘to some degree’. Only one in four said their organisations absolutely had robust systems in place.
Does your organisation have robust systems in place to implement recommendations from serious incidents?
— Verita (@VeritaUK) August 18, 2017
It can be difficult to find the time to share lessons and recommendations across staff or specialisms, especially with a pressured workforce working shifts, such as in the NHS and other regulated organisations. And, of course, learning lessons is not necessarily mandated or monitored by regulators or shareholders.
However, the impact of investing time in order to learn and share cannot be underestimated. Serious incidents can result in physical harm, abuse, significant cost, legal proceedings, and reputational damage to brand and individuals. The ultimate endpoint is, sadly, loss of life. Our experience shows that many serious incidents can be prevented or stopped if lessons are learned and recommendations implemented.
The Observer ran an article this week – Rogue doctors ‘use superhero status to abuse patients’ – based on analysis from investigations Verita has carried out recently into abuse by medical professionals. This highlighted some of the subtle warning signs that staff and management should be aware of to help spot colleagues who may be using their position in order to abuse patients.
Media coverage is a helpful way to shine a spotlight on the prevention of serious incidents, but it is not the answer. The lesson I have learned is that the most effective way to prevent avoidable incidents is for boards, regulators and professional bodies to work more closely with the relevant investigators, and systemise a proactive approach to learning and sharing so that this practice becomes the norm, and not the exception.