HSIB’s local investigation pilot

HSIB legacy content

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

Background

Our local investigation pilot was launched to evaluate HSIB’s ability to carry out effective locality-based patient safety investigations with actions aimed at specific NHS organisations, while still identifying and sharing relevant national learning.

This differs from our usual national investigations. Although our national investigations are often triggered by a specific safety incident or concern, they make safety recommendations to organisations that can make changes at a national level across the NHS in England.

The pilot was undertaken between April 2021 and April 2022.

Pilot investigations

The pilot published three investigations focused on cross boundary and multi-agency safety events:

Publications

Report

The report summarises how the HSIB local investigation pilot was undertaken, and shares findings felt to be applicable to local healthcare systems including healthcare organisations and Integrated Care Systems.

Supplementary materials

The supplementary materials provide the background to the pilot and a summary of the main evaluation findings.

Feedback

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Safety recommendations

The pilot investigations made safety recommendations to the local healthcare organisations.

The aim of the safety recommendations was to highlight issues identified during the investigations that if addressed would reduce the risk of future, similar events occurring. It was not intended for safety recommendations to offer specific solutions.

Safety observations

HSIB makes the following safety observations:

It may be beneficial if local healthcare systems consider how best to support the investigation of cross-organisation safety events as they implement the Patient Safety Incident Response Framework.
It may be beneficial if national and regional bodies consider how healthcare organisations can be supported to develop effective systems-based solutions to identified patient safety risks.
It may be beneficial if healthcare organisations develop processes to identify safety improvement themes from patient safety investigation reports.
It may be beneficial if providers of NHS care consider low-harm and no-harm safety events as sources of learning in local patient safety incident response plans.

HSIB’s local investigation pilot: shared learning for local healthcare systems

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