Open Book reports share lessons learned from adverse events

The Health Quality & Safety Commission’s Adverse Events Learning programme is working with providers to share lessons learned following review of adverse events. Key findings are published on the Commission’s website in monthly 'Open Book' case review summaries.

Each Open Book focuses on the changes a provider has made as a result of review of an adverse event, or a series of events, rather than concentrating on the incident outcome. Providers are encouraged to examine their own systems or practice in light of each review.

Open Books published to date include system changes made as a result of incident review relating to:

• swabs inadvertently retained during surgery
• correct patient identification
• heparin administration
• retained items during laparoscopic surgery.

Providers with queries about Open Books, or cases they would like to share, should please contact Commission Senior Advisor Matthew Pitt.