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Cautionary tales ? Learning from mistakes

Hoi-Ting Wong

Learning from mistakes is vital for providing safe patient care. Serious untoward incidents are reviewed by several groups within the Royal United Hospital (RUH) and the wider NHS, but communicating the learning gained from this can be difficult. ‘Cautionary Tales’ is a newsletter designed to share learning from incidents reviewed by the Division of Medicine Clinical Governance Group with junior doctors at the Royal United Hospital, UK. ‘Cautionary Tales’ is written by junior doctors, which strives to disseminate key messages and highlight common themes. Serious Untoward Incidents (SUIs) are shared in a concise manner using the SBAR format. The Assessment includes analysis of notable practice, contributory factors and the root cause. Recommendations are tailored to the hospital – often this part is also used to highlight new and existing guidelines and services. In addition, related topics are explained and consolidated (for example hyperkalaemia guidelines and how to diagnose postural hypotension). Previous newsletters have included learning points from SUIs such as falls and prescribing errors, shared Central Alerting System (CAS) alerts as well as results from a survey amongst RUH staff on complaints. ‘Cautionary Tales’ has been sharing learning points from incident reviews for two years, and has been well received by junior doctors. In a recent survey all respondents stated they enjoyed reading the newsletter and had learned from it. 96% of respondents stated they would alter their practice after reading it. In future editions, we are also hoping to include “Exemplary Tales”, where learning from excellence is promoted.