The national investigation
This national learning report is an analysis of themes in the first 22 national investigations published by HSIB. This work was undertaken as HSIB recognised that similar issues were arising in investigations that were undertaken in very different clinical fields.
The analysis used a robust, scientific approach and identified the following three recurring patient safety themes:
- access to care and transitions of care (when patients move between care providers or care settings)
- communication and decision making
- checking at the point of care.
These three themes represent the most significant threats to patient safety that HSIB has found, based on its investigations, so far.
This analysis also looked at the 85 safety recommendations made in the 22 investigations. These safety recommendations were grouped into one or more of six categories. The categories were chosen as they represent the fundamental safety management activities used across safety-critical industries:
- identification of patient safety hazards
- improving the management of known patient safety risks
- monitoring of patient safety performance
- evaluation of patient safety interventions
- training and education for patient safety
- promotion of patient safety.
Safety management systems seek to proactively mitigate threats to safety before they result in undesirable outcomes. Through the implementation of safety management systems, all those involved in safety can integrate their activities. This enables a prioritisation of actions to address safety issues and effectively manage resources.
HSIB’s work so far suggests that it may be beneficial for the NHS to explore how the application of safety management principles could build on the foundations developed by the NHS Patient Safety Strategy. The complexity of the NHS means that it is unlikely that having one single safety management system would be feasible and that a more integrated approach of multiple systems, as seen in other high-risk industries, may be necessary. A greater adoption of the principles of a safety management system in the NHS may support more effective responses to HSIB’s safety recommendations which can be a challenge in this complex environment