1. Learning from Serious Incidents: How can we move beyond a blame culture?
Chris Carey
Consultant Anaesthetist BSUH NHS Trust
Associate Postgraduate Dean HEE KSS
RCoA Council Member

2. Scale
Reported to National Reporting & Learning System (NRLS) in England
1,928,048 June
Cost unknown
No Harm
73.1
Low Harm
23.4
Moderate Harm
2.9
Severe / Death
0.54

3. Culture and Outcomes

4. SI’s on an individual level

5. System Failures

7. Impact on doctors in training

11. Discussion 1 Talk in pairs:
describe an incident that you have been involved with or that happened in you place of work
What were the contributing factors?

12. Discussion 2 Group discussion
what are the common themes that underlie untoward incidents?

13. Discussion 3 Group discussion:
what are the barriers the prevent learning from untoward incidents?

14. Discussion 4 Group Discussion:
(i) how can we overcome the barriers to learning?
(ii) how can we support trainees involved?

15. Discussion 5 Group discussion:
What sort of things can we do as individuals to improve culture and learning from untoward incidents

16. Summary

17. Thank you chris.carey@bsuh.nhs.uk