The work was undertaken after it was recognised that similar issues were arising in our investigations, even when investigations were focused on different clinical fields. This covered everything from mental health liaison services to the labelling of blood samples. Deeper qualitative analysis was then done to understand which themes arising from our investigations represented the most significant threats to patient safety.
Three key themes were identified:
- access to care and transition of care
- communication and decision making
- checking at the point of care
As well as identifying patient safety themes, the report sets out an analysis of the 85 safety recommendations made in the 22 investigations. The recommendations were grouped into six categories of ‘safety management activities.’ These categories are a fundamental part of safety management systems which take an organised approach to proactively mitigate threats to safety. They are routinely used in other high-risk industries such as aviation. The six categories are:
- 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.
The report emphasises that, whilst some of the safety management activities reflect components of existing patient safety approaches in the NHS, our 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.
Jonathan Back, Intelligence Analyst at HSIB and lead author of the report says: “ This report reflects that HSIB can collate learning from national investigations in varied healthcare settings and share that across the healthcare system. We used a robust and scientific approach to map and draw out reoccurring themes which will be of value to those working in patient safety in healthcare.
“We also concluded that using a categorisation based on principles of safety management systems supports a more organised approach to making safety recommendations which can make them more effective. It also supports a more integrated approach across a complex healthcare system such as the NHS.”