Learning when things go wrong: requires improvement

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

Characteristics of services we would rate as requires improvement in this area

Safety concerns are not consistently identified or addressed quickly enough.

There is limited use of systems to record and report safety concerns, incidents and near misses. Some staff are not clear how to do this or are wary about raising concerns.

When things go wrong, reviews and investigations are not always sufficiently thorough or do not include all relevant people. Necessary improvements are not always made when things go wrong.

The service does not always review or act on patient safety alerts or learn from external safety events.