SAERs – Joint Commission for Safety, Openness and Learning (NES and HIS) 

Until April of 2022, following an SAER in any service, colleagues could access a generic Learning Summary Template and Guidance at an Online Community of Practice on Knowledge Network. Following a review process, this will be replaced with an improved approach developed through a Joint Commission for Openness and Learning between Healthcare Improvement Scotland (HIS) & NHS Education Scotland (NES).

The joint commission in collaboration with NHS boards, will aim to develop a learning system for capturing and sharing of learning nationally. It is anticipated that this will replace the existing adverse events community of practice. This is an opportunity to modernise the existing system and to expand existing support provided to NHS boards around the management of adverse events. The approach will look at a variety of methods, including human factors and the utilisation of the existing Quality Management System, where a coordinated and consistent approach leads to a well developed learning system. You can read more about the overall approach here: here.

Involving patients and Family

The ECHO community of practice for adverse events Project ECHO will be assisting the NES/HIS joint commission for safety openness and learning to explore this further in a learning community of practice with a specific focus on what difference involving patients and family makes to the quality of the review and the learning gained. It can be accessed at

Underpinning research into what ‘good’ patient and family involvement in healthcare adverse event reviews may involve was published by the team in the BMJ in 2022.

For More information, contact the team at