A patient safety investigation is undertaken when an incident or near-miss indicates significant patient safety risks and potential for new learning.
Investigations explore decisions or actions as they relate to the situation. The method is based on the premise that actions or decisions are consequences, not causes, and is guided by the principle that people are well intentioned and strive to do the best they can.
The goal is to understand why an action and/or decision was deemed appropriate by those involved at the time.
The NHS is committed to learning from patient safety incidents to continuously improve care.
Patient Safety Incident Response Framework
The Patient Safety Incident Response Framework (PSIRF) sets out how NHS organisations should develop and maintain effective systems and processes for responding to patient safety incidents, for the purpose of learning and improving patient safety.
PSIRF promotes a proportionate approach to responding to patient safety incidents by ensuring resources allocated to learning are balanced with those needed to deliver improvement. Its focus is on how incidents happen, including factors which contribute to them.
Independent patient safety investigations
The purpose of an independent patient safety investigation (IPSI) is to capture insight to inform improvement through investigation and exploration of the care, treatment and healthcare systems and processes for one or more patients at any level of the healthcare system.
They support the NHS to:
- be open and transparent about what happened and how it happened
- identify areas for improvement to reduce the possibility of a reoccurrence of similar events
- make recommendations for the improved delivery of health services in the future which can then be acted upon by relevant organisations with the power to make appropriate changes
IPSIs are only commissioned in limited circumstances, where it is considered appropriate to dedicate additional resources to the generation of insight due to the nature of the events in question.