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TRAIL: a model to promote active learning from adverse events

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Abstract:

This article describes TRAIL, a model developed within Leicestershire Partnership NHS Trust's City Adult Mental Health Services to facilitate incident reporting and active learning from adverse events. In common with other similar trusts, Leicestershire Partnership NHS Trust has successfully implemented a risk management strategy that has encouraged staff to report adverse events, but this does not guarantee that all staff are aware of why incidents should be reported, and the challenge to move away from the 'blame culture' of old has remained real. As a service, we identified the need to move to the next stage of development that involves learning lessons from these events and engaging staff within clinical services in identifying changes required within their team practices. The TRAIL model has provided the service with a framework for identifying the lessons that could be shared more widely and raising awareness of individual and team responsibilities for maintaining safer services.

Keywords: ADVERSE EVENTS; LEARNING LESSONS; MENTAL HEALTH; PATIENT SAFETY

Document Type: Miscellaneous

Publication date: September 1, 2005

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