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Learning from negative episodes should be promoted within an ethos of support and avoidance of blame. This approach should be embedded throughout the department and the organisation as a whole.^81,82

The department should have a system for reporting, investigating, sharing learning and regular audit of critical incidents.^43,83,84,85The methodology should be explicit and should identify underlying relevant factors to inform learning and development of safe systems, as well as enabling thematic analysis, continuous monitoring and evaluation.⁷⁷

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