Nearly 1,200 people joined the second annual Patient Safety Investigation Conference on 16 September. This year’s conference focused on professional healthcare investigations, and how the Healthcare and Safety Investigation Branch (HSIB) is training staff to conduct high quality investigations. The conference also gave people an insight into HSIB's national, COVID-19 and maternity investigations.
Main session videos
Investigation science: Fundamentals of a professional safety investigation
In this session the HSIB investigation education, learning and standards team discuss the features and current progress of the science of investigation, or Investigation Science as it has been named by Dawn Benson, our head of investigation education.
The team highlights the foundations of Investigation Science in the implementation of national, organisational and team-based incident investigations in healthcare.
What HSIB has learned about the need for an organised approach to safety
The aim of investigating patient safety incidents is to learn from them by identifying safety recommendations for improvement. Many organisations, including HSIB, make safety recommendations. This presentation explores the types of recommendations that HSIB has made and where these recommendations have been targeted. Safety management principles are discussed, and HSIB reflects on whether these principles could help the NHS when attempting to improve safety.
Quality insights and safety improvements in maternity care
This workshop explored the journey of our maternity programme. It included headlines of the programmes achievements, explaining how the programme has listened, learned and improved from feedback. We shared the development of our new quality matrix and gave live examples of safety improvements made by trusts following recommendations from maternity investigations.
Family engagement workshop - family and investigator perspectives on HSIB investigations
This workshop considered patient safety investigations from the views of a family member and an investigator. It looks at investigations in three separate areas, the initial contact, the investigation process, and the difference the investigation has made. Within these areas HSIB discusses what has been considered helpful, and some take home messages for anyone delivering patient and family engagement within investigations.
COVID-19 related national investigations and reports
This session shared examples of investigations completed by HSIB during the height of the COVID-19 pandemic. This included a summary of the investigation into the supply of oxygen in hospitals and a review of 37 intrapartum stillbirths which were reported between April and June 2020. The session also considered how existing vulnerabilities within healthcare systems influenced healthcare services during the COVID-19 pandemic.
The life of a National Investigation
This session explored the national investigation process from referral of incidents to the publication of the report. The session will also provided detail of how we involve patients, families and service users during the investigation process.