Learning when things go wrong: outstanding

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

Characteristics of services we would rate as outstanding in this area

There is a genuinely open culture in which all safety concerns raised by staff and people who use service are highly valued as being integral to learning and improvement.

All staff are open and transparent, and fully committed to reporting incidents and near misses. The level and quality of incident reporting shows the levels of harm and near misses, which ensures a robust picture of quality.

Learning is based on a thorough analysis and investigation of things that go wrong. All staff are encouraged to participate in learning to improve safety as much as possible, including working with others in the system and where relevant, participating in local, national, and international safety programmes. Opportunities to learn from external safety events are identified.