Dementia Centred

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By Wendy Perry

May 27th, 2016

Learning from our mistakes

Philosopher George Santayana is credited with saying “Those who cannot remember the past are condemned to repeat it”. This quote is often used in relation to politics and world stage events, but just as accurately applies to our organisational practices.

Just this month Healthcare Improvement Scotland released a report entitled "Learning from Adverse Events" which highlights examples of good practice as well as challenges faced in learning from past adverse events across Scotland.  

Since 2013 Scotland has had its own national framework to guide care providers about how to learn from adverse events that occur within their services. Back in 2000 the Department of Health published the report "An Organisation with a Memory" in which the importance of learning from mistakes made within the NHS was highlighted. This culture of not just owning up to problems in a service but actually identifying the root of the problem and learning how to not repeat those same mistakes again has been promoted, though with varying levels of uptake. There are many challenges present in learning from organisational mistakes and unfortunately, there are no effective shortcuts.  

Of course, it is not just the NHS that needs to learn from their mistakes, all health and social care providers need to have a system for this in order to improve the quality of the services they provide and to not repeat their mistakes again. Too often, though, a quick and easy solution is sought for a larger systematic problem. Often this involves training or retraining of front line staff. Training is a key part of not repeating our mistakes, but no matter how much retraining is provided, if the organisational systems do not support practice change, then unsurprisingly the desired change will not happen. 

When we seek to improve services it is important to do a larger analysis of the systems failures and gaps that may currently exist. Not all organisations have the human resources, or knowledge base to do this, and sometimes a more objective eye is needed to see where the breakdown is occurring. The DSDC has worked with many organisations to assist them with a critical analysis of their systems to identify areas where the improvement is needed, an example output is the Trusted to Care:  An independent Review of the Princess of Wales Hospital and Neath Port Talbot Hospital at Abertawe Bro Morgannwg University Health Board. Once this has been mapped and addressed, then the training or retraining of front line staff becomes more effective. If you would like to inquire further about our deep dive services you can do so here, if you are in leadership and management and would like to improve your critical analysis skills please contact us regarding your interest at .

DSDC provides Service Consultancy, which helps to uncover issues that lead to things going wrong.

DSDC offer a Leadership and Management course in Dementia. A management and leadership development programme to develop best practice for senior staff in dementia care, suitable across health and social care, in the NHS, local authorities, private sector and the voluntary sector. 


George Santayana (1905) Reason in Common Sense, p. 284, volume 1 of The Life of Reason

Learning from adverse events through reporting and review A national framework for Scotland: Second edition

An Organisation with a Memory 

Management of adverse events Learning and improvement summary

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