3. Lessons Learned What lessons have been learned from the analysis of this event (as appropriate): At the individual level? At a care team level? At an organisational level? At the interface of primary and secondary health care? At the interface between health and social care? What action has been taken to date to minimise the chances of this event happening again? What further action do you plan? (Outline your Action Plan for Improvement and how and when you will implement it together with the role and contribution of the wider care team where appropriate. Also consider how you might share any interface issues or external factors that have contributed to this event but which you deem to be out with your control. Think again about taking a systems approach to improvement and consider the complex interactions between People, Activity and Environment already identified. If you judge that no action is necessary please justify why this is the case). Who is responsible for ensuring that these actions are implemented and how will these be monitored and sustained in practice? (Outline your role and contributions and those of the wider care team where appropriate). If you did not have the opportunity to analyse this event with colleagues, what were the barriers? (Please complete where applicable).
3. Lessons Learned What lessons have been learned from the analysis of this event (as appropriate): At the individual level? At a care team level? At an organisational level? At the interface of primary and secondary health care? At the interface between health and social care? What action has been taken to date to minimise the chances of this event happening again? What further action do you plan? (Outline your Action Plan for Improvement and how and when you will implement it together with the role and contribution of the wider care team where appropriate. Also consider how you might share any interface issues or external factors that have contributed to this event but which you deem to be out with your control. Think again about taking a systems approach to improvement and consider the complex interactions between People, Activity and Environment already identified. If you judge that no action is necessary please justify why this is the case). Who is responsible for ensuring that these actions are implemented and how will these be monitored and sustained in practice? (Outline your role and contributions and those of the wider care team where appropriate). If you did not have the opportunity to analyse this event with colleagues, what were the barriers? (Please complete where applicable).
esea-sea-report_final-version-03-july-2015.docx