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How we improve patient safety

Improving patient safety through effective and independent investigations that don’t apportion blame or liability

Most harm in healthcare comes from problems within the systems and processes that determine how care is delivered. Our investigations identify any factors that have harmed or may harm to patients. The safety recommendations we make aim to improve healthcare systems and processes, to reduce risk and improve safety.

We work closely with patients, families and healthcare staff affected by patient safety incidents, and we never attribute blame or liability.

Our investigations

Our investigators and analysts are highly experienced in healthcare and other safety-critical industries, and are trained in human factors and safety science.

We carry out patient safety investigations through two programmes:

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National investigations

Any group, organisation or person can refer a patient safety concern to us. It just needs to be about any area of NHS-funded healthcare in England.

We review these concerns against our investigation criteria to decide whether to conduct a national investigation. If we're able to go ahead, national investigation reports are published on our website and include safety recommendations for specific organisations.

Find out more about our national investigations

                A woman talks to an investigator

Maternity investigations

We investigate incidents in NHS maternity services that meet criteria set out within the Royal College of Obstetricians and Gynaecologists’ ‘Each Baby Counts’ report or the MBRRACE-UK ‘Saving Lives, Improving Mothers’ Care’ report.

Incidents are referred to us by the NHS trust where the incident took place. Where an incident meets the criteria, our investigation replaces the trust’s own.

Find out more about our maternity investigations

Who can tell us about a patient safety concern?

We welcome information about patient safety concerns from everyone, including patients and their families, the public and NHS staff.

We investigate events where something dangerous has happened, whether someone was actually harmed or not. We can also investigate unsafe conditions that could potentially cause harm.

This means you can tell us about something that has already happened, or something that you’re worried might happen if nothing is done to prevent it.

We investigate events and unsafe conditions that have happened:

  • in NHS-funded care
  • in England
  • after 1 April 2017

What is it like to take part in an HSIB investigation?

Leila Hrycyszyn describes her of experience taking part in an HSIB investigation.
Two doctors discussing results on a clipboard.

Meet our investigators

Our investigation specialists have a breadth of experience in healthcare and accident prevention. Many still hold frontline positions in the NHS and are dedicated to improving patient safety in England. You can find out more about them on our team page.

Meet the team