With people attending from all over the UK, Europe and as far away as Australia, Brazil and South Africa the appetite to learn from our independent investigations and safety recommendations is growing.
This year’s conference has focused on professional healthcare investigations, and how HSIB is training staff to conduct high quality investigations. The conference also gave people an insight into our national, COVID-19 and maternity investigations.
In the following suite of videos and slide sets we share what we have learned from healthcare safety investigations across England and give advice and content on how you can improve safety within your own organisation.
Main session videos
Investigation science: Fundamentals of a professional safety investigation
In this session the HSIB investigation education, learning and standards team discuss the features and current progress of the science of investigation, or Investigation Science as it has been named by Dawn Benson, our head of investigation education.
The team highlights the foundations of Investigation Science in the implementation of national, organisational and team-based incident investigations in healthcare.
Professionalising the investigation workforce will make a significant contribution to healthcare improvement and learning to meet strategic, policy and regulatory requirements.
Education programme: Dr Dawn Benson guides you through the courses which are being offered by HSIB and our plans for the future. The session involves a Q&A with Dawn about the courses on offer, in particular our Level 3 Award in Healthcare Safety Investigation which is open to applicants. You can find out more by emailing: InvestigationEducation@hsib.org.uk
What HSIB has learned about the need for an organised approach to safety
The aim of investigating patient safety incidents is to learn from them by identifying safety recommendations for improvement. Many organisations, including HSIB, make safety recommendations. This presentation explores the types of recommendations that HSIB has made and where these recommendations have been targeted. Safety management principles are discussed, and HSIB reflects on whether these principles could help the NHS when attempting to improve safety.
Below you'll find slide sets and videos from all of our breakout sessions.
Quality insights and safety improvements in maternity care
Synopsis: This workshop explored the journey of our maternity programme. It included headlines of the programmes achievements, explaining how the programme has listened, learned and improved from feedback. We shared the development of our new quality matrix and gave live examples of safety improvements made by trusts following recommendations from maternity investigations.
Family engagement workshop - family and investigator perspectives on HSIB investigations
Synopsis: This workshop considered patient safety investigations from the views of a family member and an investigator. We looked at investigations in three separate areas, the initial contact, the investigation process, and the difference the investigation has made. Within these areas we discussed what has been considered helpful, and some take home messages for anyone delivering patient and family engagement within investigations.
Session 3: COVID-19 related national investigations and reports
Synopsis: This session shared examples of investigations completed by HSIB during the height of the COVID-19 pandemic. This included a summary of the investigation into the supply of oxygen in hospitals and a review of 37 intrapartum stillbirths which were reported between April and June 2020. The session also considered how existing vulnerabilities within healthcare systems influenced healthcare services during the COVID-19 pandemic.
Session 4: The life of a National Investigation
Synopsis: This session explored the national investigation process from referral of incidents to the publication of the report. The session will also provided detail of how we involve patients, families and service users during the investigation process.
View the video (Timecode - 00:36:48)
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