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Learning from experience: a case study of clinical governance in action

Anita Huddleston

Objective To share the experiences of a primary care organisation in its approach to learning from experience.Design A case study approach was used to consider the effect of the ‘learning fromexperience’ group on clinical governance within a primary care trust (PCT).Setting Lincolnshire South West PCT.Results An holistic approach was taken to consider how suggestions, complaints, near misses, risks and incidents can improve organisational learning from adverse events and lead to a more effective clinical governance system for the primary care team.This was a case study and as such relates the experience of one PCT.Conclusions This approach to a systematised learning experience from adverse events could be of value for other primary care organisations.Replication of this process in other organisations may rely on key individuals being committed to the learning process.