This review by the Care Quality Commission included a sample of 74 investigation reports from 24 NHS acute hospital trusts, representing 15% of the 159 acute trusts in England.
This briefing provides a summary of the findings, linked to five opportunities for improvement:
- Prioritising serious incidents that require full investigation and developing alternative methods for managing and learning from other types of incident.
- Routinely involving patients and families in investigations.
- Engaging and supporting the staff involved in the incident and investigation process.
- Using skilled analysis to move the focus of investigation from the acts or omissions of staff, to identifying the underlying causes of the incident.
- Using human factors principles to develop solutions that reduce the risk of the same incidents happening again.