Learning when things go wrong: good

S6. Are lessons learned and improvements made when things go wrong?

Characteristics of services we would rate as good in this area

Openness and transparency about safety is encouraged. Staff understand and fulfil their responsibilities to raise concerns and report incidents and near misses; they are fully supported when they do so.

When something goes wrong, there is an appropriate thorough review or investigation that involves all relevant staff, partner organisations and people who use the service. The service participates in learning with other providers within the system.

Lessons are learned and communicated widely to support improvement in other areas where relevant, as well as services that are directly affected. Opportunities to learn from external safety events and patient safety alerts are also identified. Improvements to safety are made and the resulting changes are monitored.