HSIB’s local investigation pilot: shared learning for local healthcare systems (13 October 2022)

Summary

The Healthcare Safety Investigation Branch's (HSIB's) local investigation pilot aimed to evaluate the organisation's ability to carry out effective locality-based patient safety investigations with actions aimed at specific NHS organisations, while still identifying and sharing relevant national learning. It differs from HSIB's usual national investigations, which make safety recommendations to organisations that can make changes at a national level across the NHS in England.

The pilot published three investigations focused on cross boundary and multi-agency safety events:

• Investigation 1: incorrect patient identification
• Investigation 2: incorrect patient details on handover
• Investigation 3: transfer of a patient with a stroke to emergency care

The report summarises how the HSIB local investigation pilot was undertaken, and shares findings applicable to local healthcare systems including healthcare organisations and Integrated Care Systems.

Content

Safety observations

• It may be beneficial if local healthcare systems consider how best to support the investigation of cross-organisation safety events as they implement the Patient Safety Incident Response Framework.
• It may be beneficial if national and regional bodies consider how healthcare organisations can be supported to develop effective systems-based solutions to identified patient safety risks.
• It may be beneficial if healthcare organisations develop processes to identify safety improvement themes from patient safety investigation reports.
• It may be beneficial if providers of NHS care consider low-harm and no-harm safety events as sources of learning in local patient safety incident response plans.

The pilot investigations made safety recommendations to the local healthcare organisations. They aimed to highlight issues identified, that if addressed would reduce the risk of future, similar events occurring.