RQIA Review of the systems and processes for learning from serious adverse incidents in Northern Ireland (updated May 2023 with RQIA statement)

Summary

The Regulation and Quality Improvement Authority (RQIA) is the independent body responsible for regulating and inspecting the quality and availability of Health and Social Care services in Northern Ireland. The (RQIA) was commissioned to examine the application and effectiveness of the Procedure for the Reporting and Follow-up of Serious Adverse Incidents in Northern Ireland.

The review was conducted by an Expert Review Team established by the RQIA and made five recommendations for implementation.

Content

Summary of recommendations

The following recommendations are made to support the delivery of a new regional policy/procedure for reporting, investigating and learning from adverse events.

1. The Department of Health should work collaboratively with patient and carer representatives, senior representatives of Trusts, the Strategic Performance and Planning Group, Public Health Agency and Regulation and Quality Improvement Authority to co-design a new regional procedure based on the concept of critical success factors. Central to this must be a focus on the involvement of patients and families in the review process.
2. Health and Social Care organisations should be required to evidence they are achieving these critical success factors to the Department of Health.
3. The Department of Health should implement an evidence-based approach for determining which adverse events require a structured, in-depth review. This should clearly outline that the level of SAI review is determined by significance of the incident and the level of potential deficit in care.
4. The Department of Health should ensure the new Regional procedure and its system of implementation is underpinned by ‘just culture’ principles and a clear evidence-based framework that delivers measurable and sustainable improvements.
5. The Department of Health should develop and implement a regional training curriculum and certification process for those participating in and leading SAI reviews.