Staff from HSIB are speaking at patient safety events in Loughborough, London and New Zealand. They’ll highlight our contribution to patient safety through our investigations and share learning for the benefit of patients across the world.
Independence in investigations
There is currently a Bill going through Parliament to establish our full statutory independence. We are funded by the Department of Health and Social Care and hosted by NHS England and NHS Improvement. We operate independently and can make recommendations to any national body or organisation.
The way we operate allows us to choose what we investigate based on what will have the greatest impact for patients across the healthcare system. Our approach isn’t about attributing blame to individuals and organisations, rather focusing on the opportunities to learn. Operating within the principles of ‘safe space’ allows staff to talk to us freely about something that has happened without the fear of reprisal.
We analyse information from a varied range of sources including national incident databases, academic literature and existing national guidance and policies and anyone in England can refer their patient safety concerns to us. This allows us to launch investigations that have a real impact. The criteria we have in place makes sure that we have a check in place to make sure our investigations are working for the benefit of the healthcare system.
Our staff have experience from across the private and public sectors, with the wider team bringing lots of expertise and fresh perspectives to an evolving organisation. Our senior team and investigators come from varied backgrounds in healthcare and other safety critical industries. Some are also trained in specific areas of safety science and human factors.
Throughout the investigation process, we also engage with those who are experts in their areas – this could be a clinical specialist or someone who has lived experience of the area that we are investigating. This helps us to ensure that we are taking the investigation in the right direction.
Read our national investigation reports to see how all the expertise we use comes together.
We always work closely with patients and families from start to end of an investigation and give them a voice throughout the process. It’s important to understand their perspective of an incident and the impact it has had on their lives.
Our Head of Family Engagement, Louise Pye, has led on our innovative approach to family engagement and this year it was nominated for an HSJ Patient Safety Award. These awards recognise the organisations who continue to drive improved patient outcomes across the UK. Our nomination was a great testimony to the process we have implemented to involve patients and families. In our maternity investigations programme 91% of families approached agreed to be involved in investigations.
Making an impact on the system
When it comes to making our safety recommendations, we also engage with relevant bodies and organisations to make sure that recommendations are effective and feasible in a busy and complex environment of patient safety.
So far, we’ve made 45 safety recommendations to 19 different organisations. We’ve also made 33 safety observations and 15 safety actions have been noted – these are identified actions that have taken place during the course of the investigation. We always aim to highlight the wider work already taking place in the sector and recognise all contributions to improve patient safety.
We’ve had a response from every organisation that we have made a safety recommendation to so far. As part of our commitment to being open and transparent, we publish each safety recommendation response on our website (on each national investigation page).