Enhancing the science and practice of healthcare safety investigations

The development of formal methods of incident investigation established a scientific foundation for patient safety, showing that error and harm had to be understood in a wider organisational and system context.

We pioneered work in this area by developing frameworks (London protocol and Yorkshire Contributing Factors Framework) for investigating patient incidents that have transformed incident analysis and the review process. These methods have been adopted as best practice by national
patient safety policy makers/regulators in UK, US, Italy, France, Brazil, Australia, New Zealand and across the world.

These frameworks and the associated evidence base produced by our team (in particular, Lawton, Macrae, Vincent, O’Hara) led the way in supporting a different approach to thinking about the purpose and process of incident investigations. These methods enable a deeper, more considered analysis of incidents, embracing both success and failure, and a more strategic, system-oriented approach to recommendations and actions taken to reduce future patient risk.

Recent work has addressed the challenges of incident investigation over long time periods in the home and community. Over the last 10 years we have produced evidence (76 publications, 6,000+citations), guidance, frameworks and resources that have had a direct impact on policy and practice. The adoption of this framework internationally has impacted the investigations of hundreds of thousands of incident investigations worldwide.

Our research has also revealed that incident investigations can a devastating ‘knock on’ effect on patients, families and staff. The investigation process itself can cause additional pain and suffering to patients and families and deepen the distress of staff. To directly address the problem, we have co-produced, developed and implemented tools, resources and processes that help patients and families to be navigate the incident investigation process and that support staff who have struggled to deal with the
impact of their involvement in a patient safety incident

Finally, Macrae and Vincent developed the case for a national safety investigation agency, with a core of expertise, wider support from the service and, critically, operating independently and able to make recommendations to any part of the NHS.
This led to the establishment of Healthcare Safety Investigation Branch with which our PSRC has a close and ongoing collaboration.

We are continuing this work in the ‘Safer Systems, Culture and practices’ theme