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Candour guidance: Learning from adverse events

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30. When things go wrong with patient care, the cause is usually either a flaw in an organisational system or human error. It is important that lessons are learnt so future patients are protected from harm. Standard 5 and Standard 12 of the Standards of Practice for Optometrists and Dispensing Opticians encourage fully qualified registrants to reflect on their practice to keep their knowledge and skills up to date and to ensure a safe environment for patients.

31. As a healthcare professional, you should regularly review your own standards and performance as outlined in the Standards of Practice for Optometrists and Dispensing Opticians: ‘5.4 Reflect on your practice and seek to improve the quality of your work through activities such as reviews, audits, appraisals or risk assessments. Implement any actions arising from these’. You should take part in regular reviews and audits of the standards and performance that your team, practice or employer operates for this purpose and take steps to resolve any problems.

32. You should consider what action you can take as an individual to prevent recurrence of an adverse event.  Your employer, professional or representative body or other organisations may have in place processes or policies to help individuals to collate, review and share information on adverse events in order to improve practice and these should be used where appropriate. 

33. Depending on your role and scope of practice you might also be able to utilise a number of national schemes in the UK which are used to report adverse events and for healthcare professionals to review the learning from these events to inform good practice. These include:

a. The UK-wide Yellow Card Scheme run by the Medicines and Healthcare products Regulatory Agency (MHRA) for reporting suspected adverse drug reactions or adverse incidents involving medical devices (including spectacles and contact lenses): Please refer to the independent prescribing guidelines for optometrists for further details on adverse drug reactions. 

b. The National Reporting and Learning System for reporting adverse events and patient safety incidents in England and Wales (for registrants providing NHS care):

c. The Healthcare Improvement Scotland national framework, which outlines consistent definitions and a standardised approach to adverse event management across National Health Service (NHS) for Scotland:

d. The procedure for the reporting and follow-up of serious adverse incidents in Northern Ireland is set out on the Department of Health, Social Services and Public Safety’s website. This includes the Northern Ireland Adverse Incident Centre (NIAIC) for the voluntary reporting and investigation of adverse incidents involving medical devices, non-medical equipment, plant and building elements and for providing relevant safety guidance in relation to these items:

34. If you are an optical student then you should consult with your supervisor, tutor or training provider about any necessary action required to inform learning from adverse events that have occurred during your training.

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