Learning from Incidents

Candour achieves more when it connects to learning. Simple, reliable methods help teams translate incidents into safer systems. ^[1][2]

Root cause and contributory factors

Prioritisation by risk and feasibility keeps change practical.

^[2][3]

One or two high-use fixes are made visible at the point of work-bench checklists, PMS prompts, or signage. Owners and due dates are assigned, and quick audits or observations assess whether change has stuck. ^[2][3]

• Learning loop: capture; analyse; act; verify; share. ^[2][3]
• Verification ideas: run charts of error types; short before/after audits; patient feedback on clarity after script changes. ^[4][2]

Sharing and sustaining

Learning can be shared simply in team huddles or meetings without naming individuals. Noticing and thanking staff who raise concerns early encourages others to do the same. Induction should show new colleagues the improved way of working so old habits do not creep back. ^[5][7][2]

A shared log can track what changes have been tried and whether they worked. Actions are closed only when there is real evidence of improvement, such as fewer errors or clearer records, not just because an email was sent. If a change slips back, the approach is adjusted and tested again rather than blaming individuals. ^[2][3][7]

CPD

Learning often links to professional development. Short reflective notes might cover how to explain a referral more clearly, take more accurate measurements, or handle a difficult conversation. Supervision gives space to practise these skills, including how to phrase candour conversations. ^[6][1]

Leaders who stay curious and avoid blaming help the team improve more quickly. Simple questions such as "What made the right action difficult here?" often lead to better ideas and faster progress. For example, if referrals were delayed because the online portal often timed out, the focus shifts to fixing the system rather than criticising the staff member. ^[7][2][8]

References (numbered in text) Why we include references

1. The professional duty of candour — General Optical Council Find (opens in a new tab)
2. Patient Safety Incident Response Framework — NHS England (published 23 July 2024) Find (opens in a new tab)
3. The problem with root cause analysis — BMJ Quality & Safety — Mohammad Farhad Peerally; Susan Carr; Justin Waring; Mary Dixon-Woods (2016) Find (opens in a new tab)
4. The run chart: a simple analytical tool for learning from variation in healthcare processes — BMJ Quality & Safety — Rocco J Perla; Lloyd P Provost; Sandy K Murray (2011) Find (opens in a new tab)
5. Regulation 20: Duty of candour — Care Quality Commission (page last updated 15 November 2024) Find (opens in a new tab)
6. The reflective practitioner - guidance for doctors and medical students — General Medical Council Find (opens in a new tab)
7. A just culture guide — NHS England Find (opens in a new tab)
8. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry — Robert Francis QC (2013) Find (opens in a new tab)