Clinical and information governance proposes; human fallibility disposes

There is a strong drive within the UK's National Health Service (NHS) towards ensuring quality and reducing adverse events. This incorporates clinical governance, which applies to clinical activities, and information governance, which applies to preserving the confidentiality, availability and integrity of patient information. The purpose of this paper is to consider why humans make errors, how the current governance tools can minimise the incidence of such errors and the causatives that can increase the likelihood of an error. Errors sometimes lead to adverse events, which have to be reported. The latest adverse event reports from NHS Scotland, recently published on the BBC website, were analysed to identify major themes that emerged from the recommendations made by the investigative teams. These themes are then discussed in terms of how the current clinical governance tools should be applied to further reduce the incidence of adverse events. A revised clinical governance diagram that more clearly depicts the cross-cutting nature of the themes that emerged from the analysis is proposed. Finally some opportunities for future research are identified.

Qualitative analysis of adverse incidence reports in order to identify causatives. Used the insights delivered by this analysis in order to propose a change to Scally and Donaldson's clinical governance diagram.

A clear reliance on education and training by adverse event review teams was found, which suggests that they do not really understand what causes error, and they do not acknowledge the impact of the situation on the actors. Also – a tendency to define processes to cover all eventualities, even though some situations cannot be encoded as processes. The main insight is that there are a number of cross-cutting concerns which means that the original clinical governance diagram would benefit from a level of integration which is not currently present.

The analysed reports were severely redacted which meant that nuances of the situation could have been missed by the researcher. However, the recommendations were never redacted so the researcher focused on these.

The paper, in general, highlights the need for a more nuanced approach to clinical governance and less reliance on education and training as the universal panacea.

Over reliance on education and training puts the blame on the person, and does not acknowledge the causatives in the situation. Acknowledging the more complex nature of the problem makes adverse events less blame-worthy and more likely to lead to real learning and effective mitigation.

The author is not aware of anyone else having analysed these reports.