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Healthcare Safety Investigation Branch

Independent safety investigations in �NHS-funded care

Do not apportion �blame or liability

Focus on system-level (policy and regulatory) change

Professionalise the patient safety investigator role

Established in 2017 as a new body to undertake independent safety investigations of patient safety incidents in NHS-funded care, in England. We work cooperatively on patient safety with NHS central bodies but are functionally separate and independent. Encourage improvement in patient safety and safety culture that’s been achieved in other safety critical industries.

HSIB’s purpose is to identify the safety risks, follow the evidence and develop effective safety recommendations. We do not apportion blame or liability. Model through investigations the values and behaviours that support transparency and blame-free learning.

Our purpose is to focus on identifying patient safety risks that exist at system level – that are consequences of misalignment between policy and regulation and the realities of caregiving at the frontline, and that can be observed recurring across the NHS.

4. Intend to professionalise the role of safety investigation, support NHSI national patient safety training curriculum and improving standards of local investigations.

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Introduction

The aim of investigating patient safety incidents is to learn from them by identifying areas for improvement

HSIB recognised that similar issues were arising in our investigations and a method for identifying themes was developed based on SEIPS

SEIPS is also used to inform our evidence collection but the focus of this presentation is on HSIB’s Safety Incident Research (SIRch) database, which uses a SEIPS taxonomy

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What is SIRch?

SIRch codifies and combines the internationally recognised Systems Engineering Initiative for Patient Safety (SEIPS) method with the incident categories used by NHS England and Improvement’s Learn from Patient Safety Events (LFPSE) service

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Why this is important?

Significantly improve HSIB’s capacity to generate National Learning Reports (aggregating findings)
Allow for the systematic identification of safety risks and topic areas for new investigations
Allows external organisations to use HSIB datasets for safety studies including AI (subject to approvals)
Might be used not just within HSIB, but more widely in the NHS

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Method

Investigation

Report

Safety Intelligence Research (SIRch)

Coded Narrative

NVivo

Contributory Factors	Frequency (%)
Job demands (e.g. workload, time pressure, cognitive load)	7
Senior review not conducted	14
Team coordination	5

- Clinical factors (e.g., BMI)

Socioeconomic/geographical - (e.g., access to healthcare, region)
Patient factors (ethnicity, language barriers)

- Quality of care delivery factors (e.g., staff workload, team working)

Codes

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Aggregated codes (example)

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Thematic analysis of patient safety themes

Highlights recurring patient safety themes which could be of value to those working in patient safety in healthcare – national concerns reflected locally?

Demonstrates a qualitative analysis of HSIB’s national investigations in a way which could be of interest to those working in patient safety science

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Access to care and transitions of care

If services are available, then the opportunity to obtain healthcare exists

However, barriers also exist, and these can prevent appropriate access to care and can cause problems during transitions of care (i.e., when changing care providers)

Identified using SIRch: These barriers can be financial, organisational, social, or cultural

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Communication and decision making

The delivery of healthcare is dependent on timely communication and effective decision making

Identified using SIRch: There are many situations where pressures on the healthcare system can impact on the reliability of communication and decision making processes

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Checking at the point of care

Many routine activities require healthcare workers to check that the intended treatment is being delivered correctly.

Identified using SIRch: The aim should be to reduce the reliance on checking by developing procedures that mitigate against known risks by design.

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Conclusions

HSIB recognised that similar issues were arising in our investigations and a method for identifying themes was developed

Potentially useful across the system?
National concerns reflected locally?

Allow for the systematic identification of safety risks and topic areas for new investigations
Allows external organisations to use HSIB datasets for safety studies including AI (subject to approvals)
Might be used not just within HSIB, but more widely in the NHS