Recording, reporting, and learning from incidents

Candour does not end with an apology. Incidents and near misses must be recorded promptly, reported appropriately, and followed by clear learning actions; otherwise the same unsafe system can harm someone else.

What should be recorded

• What happened, when, and how it was discovered
• What was supplied, said, done, or omitted
• Who was told and when: patient, carer, prescriber, manager, owner, or another service
• What immediate safety advice or remedy was given
• What follow-up was arranged
• What learning points or review actions were identified

Reporting should improve the system

Reporting is for understanding and reducing risk, not for making numbers look better. Candour, complaints handling, incident reporting, and near-miss reporting should link so recurring problems become visible.

• Notice patterns: repeated labelling errors, delivery failures, unclear task ownership, booking problems, or privacy breaches are signs of system problems.
• Share learning with the right people: this includes colleagues beyond the person involved.
• Review local processes: check SOPs, staffing, training, templates, storage, checking systems, communication routes, and service design for necessary changes.
• Escalate where required: some incidents need senior, contractual, regulatory, or indemnity input as well as local review.

What managers and supervisors should review

Do not alter records to make an incident look better. If clarification is needed, add a dated factual note or correction rather than rewriting history.