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The department should have a process to disseminate learning from incidents widely, both within the department and elsewhere in the organisation where appropriate.

Within the process for dealing with critical incidents, positive feedback should be emphasised and changes made to avoid recurrence.

It is the organisation’s responsibility to ensure that patient safety concerns are addressed.  An organisation with an effective safety culture should engage the team involved with working out where improvements might come rather than investigating at a distance and recommending the introduction of a change to be implemented by others.⁸⁶

It is important that local reporting systems should feed into national reporting systems, where relevant.⁸⁶ Anaesthetists should contribute data as required, with the support of their organisation.

There should be multi professional involvement in the review of critical incidents and near misses and in reviewing and learning from clinical excellence.⁸⁷

Colleagues involved in reviewing significant adverse events should have appropriate education and training which includes an understanding of human factors and the complexity of healthcare systems.⁸⁷

All staff should recognise and act upon their duty of candour and should foster a culture for reporting incidents and concerns with confidence that the focus of the organisation is on learning and improvement rather than blame.^14,78 Adequate information sharing and feedback, as well as avoidance of blame, are essential to encouraging staff to value and therefore engage with the system.⁸⁷

Departments should consider having a means of identifying those colleagues who have been involved in a patient safety incident and providing an opportunity for them to talk about what has happened and the impact it has had on them in a confidential and supportive environment.^87,88

Departments should have a clear and readily available plan accessible to all members of the anaesthetic team to manage adverse events both for a patient and beyond for a colleague/s or the department.  This might include exploring the possibilities of interdepartmental peer support groups, and strategies to reduce the emotional burden on staff after adverse events.^89,90,92,93

The department should provide training and education in dealing with adverse events including: what to do after an adverse incident, potential problems, appropriate communication skills, the law surrounding adverse incidents and where to find expert support. ^43,91,92,95