Improving incident investigation through the involvement of patients and families

In 2009, researchers based within this partnership commenced what has become a large body of research work that explores how patients and families can contribute to patient safety. We have generated knowledge about how patients can: identify and report risks, safety concerns and patient safety incidents; work with staff to improve healthcare services; and, support the safety of their own care and reduce adverse outcomes. We also identified, through this work, that patients and families were largely ignored as sources of safety intelligence during serious incident investigations. In 2019, Jane O’Hara, Carl Macrae, Rebecca Lawton and colleagues were awarded £900K by the NIHR to develop and test new ways to better involve patients and families following healthcare harm. Our partners in this work have been four NHS Trusts and the Healthcare Safety Investigation Branch (HSIB). We have worked with over fifty people from across the healthcare community – from patients, families and staff, through to investigators, lawyers and policy makers – to co-produce new materials and guidance to support involvement in serious incident investigations. This work has had two significant impacts. First, HSIB have committed to incorporating outputs from this research into their already highly regarded approach to patient and family engagement, as well as our findings feeding into their national level Investigation Science Education Programme. Second, through working closely with the NHSEI Patient Safety Team since the start of this programme, our research has directly informed the guidance for the
involvement of patients and families that will accompany the new Patient Safety Incident Response Framework, due to be rolled out in April 2022. The NHSEI Patient Safety Team are basing the guidance blueprint on our developed materials, and our evaluation work over the last twelve months provided the basis for the final iteration of the national involvement guidance published in April 2023.

You can learn more about the work we’ve done here.

Supporting publications:

O’Hara JK, Isden R. Identifying risks and monitoring safety: the role of patients and citizens. London: The Health Foundation.2013 Oct.

O’Hara JK et al. What can patients tell us about the quality and safety of hospital care? Findings from a UK multicentre survey study. BMJ Quality & Safety. 2018 Sep 1;27(9):673-82.

Cribb A, O’Hara JK, Waring J. Improving responses to safety incidents: we need to talk about justice. BMJ Quality & Safety Published Online First: 20 January 2022. doi: 10.1136/bmjqs-2021-014333.