Traps to avoid in safety investigations, education and practice (NES, October 2021)

Summary

In this article, Professor Paul Bowie, Programme Director for Safety & Improvement at NHS Education for Scotland (NES), outlines an NES research project which aimed to critically review the safety-related content, language and assumptions of a small but diverse range of health and care safety learning reports, policies, databases and curricula.

Content

The following information sources, which were in the public domain or volunteered by care organisations, were selected for review:

• NHS Board Adverse Event Learning Summaries
• Ombudsman Reports on Complaints
• Data from incident reporting and learning systems
• National and organisational management of adverse events policies
• Organisational incident investigation reports
• National and international patient safety curricula

The study identified the following issues in the information reviewed:

• Omitting the ‘systems approach’
• Using the language of blame and human failure
• Overlooking the ‘local rationality’ principle
• Engaging in counterfactual reasoning
• Misunderstanding key concepts

Related reading: 

• HSIB: Learning Response Review and Improvement tool