The Patient Safety Strategy (2019) and Patient Safety Investigation Framework (PSIRF) both outline a fundamental shift in the way that patient safety investigations are conducted. This ‘new era’ in patient safety represents a considerable shift in the way that investigations are conducted, particularly for those NHS Trusts implementing PSIRF.
As the Serious Incident Framework (2015) becomes obsolete, how teams select their incidents to investigate will shift away from severity of harm to focusing on pinpointing opportunities to maximising learning. Indeed, under the new arrangements, teams are encouraged to consider utilising a wider range of investigation techniques that will ensure a more proportionate and potentially less time-consuming approach to understanding sub-standard care and failings. With an emphasis on systems thinking and human factors, organisations will need to identify and train expert investigators. The days of individual investigators analysing incidents will disappear as skilled teams put patients and their families at the heart of the investigation process, engaging proactively and with compassion. Organisations must also consider how they will best support teams carrying out the challenging and demanding task of investigating patient safety incidents.
Historically, patient safety investigations have led to weak actions that are often viewed as unfeasible and/or not implemented. Investigations must result in clear and robust safety actions, with detailed methodologies stating how these actions will be checked and reviewed. In addition, reports must adopt the national template for patient safety investigations and follow the relevant reporting guidance. At many levels, clinical audit will play an increasing role in patient safety investigations and organisations need to understand how audit can enhance this field of work.
Moreover, new national standards for conducting patient safety investigations have been published by NHS England and these underpin this vital work, providing clear guidance on what is expected and viewed as best practice.
Key Learning Outcomes:
Understand the new patient safety landscape
Understand the need for proportionality when conducting investigations
Explain the new national patient safety standards and what they mean for investigators
Understand key skills needed by patient safety investigators in 2023
Understand vital tools to help pinpoint contributory factors
Understand what an effective patient safety action plan looks like.
