Learning from adverse events

It is crucial to continually improve person-centred care that is safe and effective. An adverse event can be defined as an event that could have caused, or did result in, harm to people or groups of people. Adverse events should be regarded as an opportunity to learn and to improve in order to increase safety.

It is important that there are robust and reliable processes in place to effectively manage adverse events, and that lessons are shared widely and used to support improvements in patient care and service delivery.

Even apparently simple human errors almost always have multiple causes, many beyond the control of the individual who makes the mistake. Therefore, it makes no sense at all to punish a person who makes an error, still less to criminalise it. The same is true of system failures that derive from the same kind of multiple unintentional mistakes. Because human error is normal and, by definition, is unintended, well-intentioned people who make errors or are involved in systems that have failed around them need to be supported, not punished, so they will report their mistakes and the system defects they observe, such that all can learn from them."
The best way to reduce harm ... is to embrace wholeheartedly a culture of learning." A promise to learn – a commitment to act, The National Advisory Group on the Safety of Patients in England, chaired by Don Berwick, August 2013