HSSIB Investigation Report. Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development

Summary

This report shares learning and insights from Health Services Safety Investigations Body's (HSSIB) education and investigation teams about patient safety incident investigation under the Patient Safety Incident Response Framework (PSIRF). It is intended for national and local organisations and policymakers to help inform future work to support staff in system-based investigation across the NHS in England.

You can read Patient Safety Learning's response to this report here.

Content

Summary of learning and insights about patient safety incident investigation under PSIRF identified in this report:

Applying investigation tools, templates and guidance

• The shift to a system-based approach to investigation, which avoids blaming individuals when incidents happen, has been positively received by staff.
• Using system-based tools is a skilled activity. Expertise builds over time with practice, support and guidance from those with existing expertise and experience.
• Currently there is a gap between staff’s awareness that there are tools and guides in the PSIRF toolkit and having the necessary support and expertise to be able to use them in practice.
• Training for staff has provided limited opportunities for them to practically apply and discuss using the tools and guides in the toolkit.
• The current design of some PSIRF tools and guides may limit staff’s ability to use them in practice.
• Feedback indicates staff find it particularly challenging to apply the tools and guides in investigations about mental health care.

Engaging and involving those affected by patient safety incidents

• The principle of greater engagement and involvement in investigations is welcomed by staff and seen as the right thing to do.
• Progress towards greater engagement is variable depending on the organisational support available to enable this work.
• Time pressure was the main reason given for continuing to rely on statements from those involved in incidents rather than gathering
• information through interviews and discussions as recommended by PSIRF.
• Conversations which involve apologising to a patient, family or carer for harm caused during their care require specific knowledge, skills and attributes as detailed in the PSIRF patient safety investigation standards.
• Specific challenges in engaging with patients, families and carers were highlighted in investigations in mental health organisations.

Organisational support for patient safety incident investigation

• Organisational support and informed oversight are fundamental and essential conditions to enable the shift to a system-based approach to investigation with meaningful involvement of those affected.
• Boards and senior leaders have a powerful influence on the approach and practice of investigations.
• Some organisations have invested in implementing PSIRF and have provided the organisational support needed, for example by establishing safety teams with dedicated investigators and engagement leads, which also provide a space for sharing and learning.
• Some organisations have not invested in implementing PSIRF and progress has been limited by the lack of dedicated roles and resource. For example, some staff have attended PSIRF training in their own time as their organisation has not provided protected learning time.

External influences on investigation practice

• The lack of central funding for PSIRF implementation may have contributed to the variation in support provided within organisations to implement it.
• Greater oversight of PSIRF implementation in organisations is needed to help ensure consistency in how PSIRF is understood and applied in NHS trusts.
• Investigations involving multiple providers are difficult for a single organisation to co-ordinate.
• Integrated care boards have not always been able to provide the support and co-ordination needed for cross-provider investigations as expected under PSIRF. This means investigations often focus on one element of a patient’s journey, missing valuable learning and meaningful improvement opportunities.
• Coroners’ expectations can influence an organisation’s choice of learning response to an incident.

Other PSIRF learning responses

• Staff value having the flexibility to choose a range of learning responses to patient safety incidents.
• After action review is the chosen learning response to many incidents that previously would have triggered an investigation. It is important that facilitators are appropriately trained and that the governance processes for this learning response are robust.
• There is interest in and an aspiration to use thematic analysis but there are challenges with applying this method which mirror those of applying system-based tools.