Learn, Do Not Copy!

Act on lessons learned from incidents that occur

This page is designed to answer the following questions:

NOTE: Although this page has been marked as complete, it has not yet been peer-reviewed or quality-assured, therefore it should be considered a ‘first draft’ and any information should be fact-checked independently.

Even with the best-laid plans, things may not work as intended, so it is essential to learn from any incidents that occur within your organisation. For this assessment criterion, you will be required to show evidence of how incidents have informed your leadership and management of service practice in respect of person-centred care.

The primary reason for investigating and reflecting on incidents is to improve practice and prevent them from happening again. Therefore, you must foster an open and honest culture within your organisation, whereby team members and service users feel comfortable about raising concerns and will not fear recriminations for doing so. Whilst disciplinary action may be required in some circumstances, the primary focus should be on learning.

Areas that you should consider include:

Identified poor practice

When poor practice within your organisation is identified, you must address it as soon as possible and try to discover the reasons for the failings so that you can put actions in place to improve it. For example, if weekly drug stock checks are resulting in errors, you may wish to introduce daily drug stock checks to try to identify exactly where the issue lies.

When an individual is demonstrating poor practice, performance management protocols should be used to try and get the team member up to par. A full and frank discussion with the individual about their performance will be needed to identify the root cause of the problem. Perhaps they do not understand the policies and procedures or they feel that their training was not up to scratch.

It is important to try not to blame the individual and instead support them to improve by giving them clear instructions and time to make the changes to their practice. The discussion with the team member may unveil systematic issues within the organisation, such as written procedures being ambiguous. In these cases, steps should be taken to improve the clarity of the procedures.

If a team member’s practice continues to be poor after being given opportunities to improve, disciplinary procedures may need to be invoked.

Accidents, errors and ‘near-misses’

All accidents, errors and near-misses that occur within your organisation must be logged and each incident should be investigated and reflected on so that changes can be made to prevent it from happening again. In addition, the entire log should be reviewed by a manager on a regular basis to see if there are any patterns or trends that may indicate a common theme that needs to be addressed.

Concerns and complaints – formal and/or informal

Similarly, each concern and complaint should be addressed according to your organisation’s policy and procedure and the log reviewed to identify any patterns that may be present.

You should maintain records of all accidents, errors, near-misses and complaints that you have dealt with so that there is an audit trail of your actions and to support you to justify any decisions that you make. These records should contain the incident, how it was investigated, the results of the investigation and the changes that were made to prevent it from happening again.