Every day more than a million people are treated safely and successfully in the NHS.
When patient safety incidents do happen, the effects can be devastating. It is essential that everyone involved in the incident is properly supported and that a just, open and transparent approach is adopted.
It is also important that NHS organisations use information from incidents to establish what they can tell us about our healthcare systems.
Patient safety incident investigation (PSII) resources
PSIIs offer the opportunity for in-depth study in response to key patient safety incidents. Safety investigations are conducted to identify how and why certain patient safety incidents happen. They include data collection and analysis phases to learn more about system-based underlying factors and their interdependencies. Recommendations and improvement plans are then designed to effectively and sustainably address those system factors and help deliver safer care for our patients.
PSIIs are conducted for systems improvement. They are not inquiries into the cause of death, nor to apportion blame or hold individuals or organisations to account. For those purposes, it is important that incidents are referred to other relevant independent organisations who are specialists in conducting those types of investigation.
- The Serious Incident Framework (SIF) - This is the current policy for the NHS that sets out when and how NHS-funded healthcare organisations should undertake a PSII..
- Patient Safety Incident Response Framework (PSIRF) - Once it has been tested with a small number of early adopter systems, this will replace the SIF. It is designed to guide NHS funded healthcare organisations in their response to and management of patient safety incidents. The PSIRF endorses systems-based PSIIs.
A template to guide local early adopter organisations in prioritising investigation quality over quantity
Standards for commissioners, boards and investigators in the commissioning, oversight, conduct and use of PSIIs
- Duty of Candour (Regulation 20) - Sets out some specific requirements that providers must follow when things go wrong with care and treatment, including informing people about the incident, providing reasonable support, providing truthful information and an apology.
- Being open – Saying sorry when things go wrong - Guidance on communicating about patient safety incidents with patients, families and carers and how to discharge our duty of candour effectively.
- Guidance for NHS trusts working with bereaved families and carers - Advice for the NHS on how to engage and work effectively with families following a death.
- Information for bereaved families - Guidance available to share with families following bereavement.
- Just Culture Guide - This HR tool guides managers to treat staff involved in a patient safety incident in a consistent, constructive and fair way. The guide should not be used as an integral part of a PSII, since the specific aim of PSII is system learning and improvement. The guide supports a conversation between managers and staff about whether a staff member involved in a patient safety incident requires specific individual support or intervention to work safely, It should not be used routinely. Remember, you have moved into individual practitioner performance investigation when it is suggested an individual needs support to work safely, as opposed to a whole cohort of staff, which would be examined as part of a PSII.
Patient safety incident investigation tools
The following are provided as an adjunct to investigation training. Patient safety investigation is an important and complex task. It is not intuitive and should not be undertaken by those who have not attended training and gained skills and experience from specialists in the field.
A template to assist in the compilation of a timeline/chronology of events leading up to a patient safety incident. A flowchart or a two-dimensional depiction of the work/task can add great value.
A taxonomy of key factors (including ergonomic and human factors), which underlie patient safety incidents.
A tool designed for use in conjunction with the contributory factors framework above, to guide and organise the analysis of interconnected, contributory, causal and mitigating factors
A template to identify and document variations to policy, protocol or expected practice (work as imagined). It is important to note that variations are common and are most often the result of efficiency-thoroughness trade-offs.
A template to prioritise problems and their further analysis.
A tool to assess and compare the relative efficacy, value and cost of a range of solutions. This can be used either at the improvement development stage, or after the solutions/improvements have already been implemented.
- Risk assessment tool - A tool to assess the likelihood and severity of identified hazards in order that risks can be determined, prioritised, and sensible control measures applied (eg clinical, safety, business risks).
Review methods/tool (more appropriate alternatives to investigation)
- Incident Recovery - Taking urgent measures to address serious and imminent: discomfort, injury, threat to life, damage to equipment or the environment.
- Case record review/Case note review - To determine whether there were any problems with the care provided to a patient by a particular service (when routinely identifying the prevalence of issues; or when bereaved families/carers or staff raise concerns about care).
- 'Being open’ conversations - To provide the opportunity for a verbal discussion with the affected patient, family or carer about the incident (what happened) and to respond to any concerns.
- Hot debrief - To conduct a post-incident review as a team by discussing and answering a series of questions
- Safety huddle - A short multidisciplinary briefing, held at a set time and place and informed by visual feedback of data to:
- improve situation awareness of safety concerns
- focus on the patients most at risk
- share understanding of the day’s focus and priorities
- agree actions
- enhance teamwork through communication and collaborative problem-solving
- celebrate success in reducing harm.
- After-action review - A structured, facilitated discussion on an incident or event to identify a group’s strengths, weaknesses and areas for improvement by understanding the expectations and perspectives of all those involved and capturing learning to share more widely
- LeDeR (Learning Disabilities Mortality Review) - To review the care of a person with a learning disability (recommended alongside a case note review
- Perinatal mortality review tool - A systematic, multidisciplinary, high quality audit and review to determine the circumstances and care leading up to and surrounding each stillbirth and neonatal death, and the deaths of babies in the post-neonatal period having received neonatal care
- Mortality review - A systematic review of a series of case records using a structured or semi-structured methodology to identify any problems in care and draw learning or conclusions that inform action needed to improve care, within a setting or for a specific patient group, particularly in relation to deceased patients
- Audit - To systematically determine whether the activities, resources and behaviours and outcomes are as expected/intended
- Clinical Audit - A quality improvement cycle involving measurement of the effectiveness of healthcare against agreed and proven standards for high quality, with the aim of then acting to bring practice into line with these standards to improve the quality of care and health outcomes
- Risk assessment - To determine the likelihood and severity of identified hazards and apply sensible measures to control those risks (eg clinical, safety, business).
Responding to patient safety incidents patient story videos
We have produced a series of patient story videos to be used as training resources for NHS organisations to demonstrate the impact the initial response to a patient safety incident and subsequent investigation has on the patient.
- Responding to patient safety incidents – Kathryn’s story
- Responding to patient safety incidents – Kirsty’s story
- Responding to patient safety incidents – Valerie’s story
- The future of patient safety investigation - Recorded webex presentation