Serious Incidents Reporting
At Verita, we understand that weaknesses in investigating serious incidents can lead to reputational damage and costly legal claims, as well as missed opportunities to make services safer.
Our serious incident management service ranges from conducting individual investigations and thematic reviews, consultancy, training and diagnostics. We have drawn on our experiences with health organisations in over 200 serious incident investigations to develop solutions that give the information needed to target problem areas, quality assure investigations and investigative processes, prevent backlogs and increase organisation-wide learning.
Verita have helped health providers improve such that the regulator has lifted warning notices about their serious incident processes. Trusts come to Verita to assure themselves and the regulator that they have robust systems in place to investigate serious and critical incidents so that themes are identified and lessons learned.
We assess individual serious incident reports and conduct thematic reviews of multiple reports to flag areas of weakness and offer evidence-based recommendations on how to improve.
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How serious incident investigations work
We write adverse incident handbooks and deliver systematic incident investigation training for organisations to help them embed and maintain robust systems for managing serious incidents. Our CPD accredited training covers each step of the systematic investigative process including root cause analysis. Our courses teach techniques on applying human error theory, securing and collating evidence, using investigative tools, developing chronologies, analysing evidence, writing reports and developing SMART recommendations.
We also test the strength of newly introduced policies by benchmarking against national standards and meeting with senior staff across clinical directorates to assess their understanding and emphasise the importance of conducting and learning from investigations. We identify ways in which such policies and their implementation can be improved and put forward practical recommendations on how organisations can embed learning.
In order to better achieve this, we employ the use of our ‘serious incident diagnostic tool’ to help trusts pinpoint weaknesses in their serious incident management processes, often in trusts with a backlog of cases pending investigation. Using our tool we test compliance against seven best-practice standards drawn from national guidance: board recognition, system efficiency and quality, staff engagement, resources and infrastructure, the investigation, learning from serious incidents and involving third parties.
Our diagnostic identifies whether boards are committed to investigating incidents, whether teams are adequately resourced, whether authors are sufficiently challenged and whether action plans are SMART. We also assess whether third parties are involved in investigations in accordance with local and national guidelines.
We offer practical advice on effectively managing serious incidents the first time. This advice is grounded in our experience, national guidance and the use of interview testimony and documentary review. The result is a reliable and cost-effective service that promotes learning and helps to reduce the need for later expensive action.
If you would love to read more about the work that Verita has done in relation to Serious Incidents, please click on the additional articles below: