Methodology and guidance: How to do an investigation

Articles in this category

1. Top picks: Safety investigations in other industries

   • Investigation
   • Rail and Maritime
   • (and 6 more)

     Tagged with:

     • Investigation
     • Rail and Maritime
     • Aviation
     • Healthcare
     • Organisational learning
     • High reliability organisations
     • Nuclear
     • Top picks

   By Patient Safety Learning, 36 minutes ago

   • 0 comments
   • 23 views
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   • Added by Patient Safety Learning
   • 36 minutes ago

2. Development of a competency framework for healthcare safety investigators: An E-Delphi study (21 February 2026)

   • Investigation
   • Competency framework
   • (and 2 more)

     Tagged with:

     • Investigation
     • Competency framework
     • Patient safety incident
     • System safety

   By Patient Safety Learning, 21 February

   • 2 comments
   • 1,334 views
   • 
   • Comment by Mark Hughes
   • 9 September, 2025

3. Facilitating After Action Reviews (AARs) isn’t just a process—it’s a psychological workout (Judy Walker Associates, August 2025)

   • After action review
   • Bias
   • (and 4 more)

     Tagged with:

     • After action review
     • Bias
     • Patient safety incident
     • Investigation
     • PSIRF
     • Unconscious bias

   By Patient Safety Learning, 3 September, 2025

   • 0 comments
   • 468 views
   • 
   • Added by Patient Safety Learning
   • 3 September, 2025

4. The quiet engine of quality: AAR’s power (Judy Walker Associates, July 2025)

   • After action review
   • PSIRF
   • (and 2 more)

     Tagged with:

     • After action review
     • PSIRF
     • Patient safety incident
     • Investigation

   By Patient Safety Learning, 28 July, 2025

   • 0 comments
   • 450 views
   • 
   • Added by Patient Safety Learning
   • 28 July, 2025

5. Is the “expectations” question, the most important one? (Judy Walker Associates, June 2025)

   • After action review
   • Communication

   By Patient Safety Learning, 18 June, 2025

   • 0 comments
   • 318 views
   • 
   • Added by Patient Safety Learning
   • 18 June, 2025

6. Scottish Government. Maternity and neonatal (perinatal) adverse event review process: guidance (15 September 2021)

   • Scotland
   • Patient safety incident
   • (and 2 more)

     Tagged with:

     • Scotland
     • Patient safety incident
     • Investigation
     • Maternity

   By Patient Safety Learning, 22 May, 2025

   • 0 comments
   • 305 views
   • 
   • Added by Patient Safety Learning
   • 22 May, 2025

7. The Learn Together programme (part B): evaluating co-designed guidance to support patient and family involvement in patient safety incident investigations (22 April 2025)

   • PSIRF
   • Patient safety incident
   • (and 5 more)

     Tagged with:

     • PSIRF
     • Patient safety incident
     • Investigation
     • Patient / family support
     • Patient / family involvement
     • Transparency
     • Communication

   By Patient Safety Learning, 12 May, 2025

   • 0 comments
   • 424 views
   • 
   • Added by Patient Safety Learning
   • 12 May, 2025

8. Being fair tool: Supporting staff following a patient safety incident (NHSE, 9 May 2025)

   • Organisational culture
   • Patient safety incident
   • (and 3 more)

     Tagged with:

     • Organisational culture
     • Patient safety incident
     • Staff support
     • Decision making
     • Investigation

   By Patient Safety Learning, 9 May, 2025

   • 0 comments
   • 1,105 views
   • 
   • Added by Patient Safety Learning
   • 9 May, 2025

9. Duty of Candour: Frequently Asked Questions

   • Duty of Candour
   • Transparency
   • (and 8 more)

     Tagged with:

     • Duty of Candour
     • Transparency
     • Patient safety incident
     • Investigation
     • PSIRF
     • Patient / family involvement
     • Patient / family support
     • Communication
     • Organisational culture
     • Regulatory issue

   By Patient Safety Learning, 1 April, 2025

   • 1 comment
   • 16,434 views
   • 
   • Comment by Sam
   • 1 April, 2025

10. Patient Safety Management Network: Strengthening understanding of Duty of Candour through collaboration

    • Duty of Candour
    • Transparency
    • (and 7 more)

      Tagged with:

      • Duty of Candour
      • Transparency
      • Communication
      • Patient safety incident
      • Patient / family involvement
      • Patient / family support
      • Organisational culture
      • PSIRF
      • Regulatory issue

    By Patient Safety Learning, 1 April, 2025

    • 0 comments
    • 1,154 views
    • 
    • Added by Patient Safety Learning
    • 1 April, 2025

11. The Learn Together programme (part A): co-designing an approach to support patient and family involvement and engagement in patient safety incident investigations (26 March 2025)

    • Patient / family involvement
    • Investigation
    • (and 4 more)

      Tagged with:

      • Patient / family involvement
      • Investigation
      • Patient safety incident
      • PSIRF
      • Transparency
      • Communication

    By Patient Safety Learning, 27 March, 2025

    • 0 comments
    • 503 views
    • 
    • Added by Patient Safety Learning
    • 27 March, 2025

12. Investigators are human too: outcome bias and perceptions of individual culpability in patient safety incident investigations (10 October 2024)

    • Investigation
    • Patient safety incident
    • (and 2 more)

      Tagged with:

      • Investigation
      • Patient safety incident
      • Bias
      • Human factors

    By Patient Safety Learning, 24 February, 2025

    • 0 comments
    • 503 views
    • 
    • Added by Patient Safety Learning
    • 24 February, 2025

13. Don’t be nice in a debrief (Judy Walker, 4 February 2025)

    • After action review
    • Patient safety incident

    By Patient Safety Learning, 6 February, 2025

    • 0 comments
    • 297 views
    • 
    • Added by Patient Safety Learning
    • 6 February, 2025

14. Spot the difference: The “Lesson Learned Report” and the “After Action Review” and why it matters today (30 October 2024)

    • After action review
    • Organisational learning
    • (and 2 more)

      Tagged with:

      • After action review
      • Organisational learning
      • Methodology
      • Investigation

    By Patient-Safety-Learning, 3 January, 2025

    • 0 comments
    • 647 views
    • 
    • Added by Patient-Safety-Learning
    • 3 January, 2025

15. System analysis of clinical incidents: The London Protocol 2024

    • Patient safety incident
    • Investigation
    • (and 5 more)

      Tagged with:

      • Patient safety incident
      • Investigation
      • Organisational learning
      • Patient / family involvement
      • Organisational culture
      • System safety
      • Implementation

    By Patient Safety Learning, 4 October, 2024

    • 0 comments
    • 13,137 views
    • 
    • Added by Patient Safety Learning
    • 4 October, 2024

16. After Action Review: Barriers and enablers to implementation (4 June 2024)

    • After action review
    • Investigation
    • (and 2 more)

      Tagged with:

      • After action review
      • Investigation
      • Implementation
      • PSIRF

    By Patient-Safety-Learning, 27 July, 2024

    • 0 comments
    • 661 views
    • 
    • Added by Patient-Safety-Learning
    • 27 July, 2024

17. MNSI Webinar on Local Rationality Questions

    • Investigation
    • Staff engagement
    • (and 1 more)

      Tagged with:

      • Investigation
      • Staff engagement
      • Interview

    By Patient_Safety_Learning, 14 May, 2024

    • 0 comments
    • 726 views
    • 
    • Added by Patient_Safety_Learning
    • 14 May, 2024

18. The process and perspective of serious incident investigations in adult community mental health services: integrative review and synthesis (4 January 2024)

    • Investigation
    • Mental health - adult
    • (and 4 more)

      Tagged with:

      • Investigation
      • Mental health - adult
      • Self harm/ suicide
      • Organisational learning
      • Root cause anaylsis
      • Safety II

    By Patient-Safety-Learning, 18 March, 2024

    • 0 comments
    • 710 views
    • 
    • Added by Patient-Safety-Learning
    • 18 March, 2024

19. WHO: Minimal Information Model user guide (14 September 2018)

    • Patient safety incident
    • Data
    • (and 2 more)

      Tagged with:

      • Patient safety incident
      • Data
      • Organisational learning
      • PSIRF

    By Patient Safety Learning, 5 March, 2024

    • 0 comments
    • 859 views
    • 
    • Added by Patient Safety Learning
    • 5 March, 2024

20. NHS England: Swarm huddle (August 2022)

    • Patient safety incident
    • Organisational learning
    • (and 4 more)

      Tagged with:

      • Patient safety incident
      • Organisational learning
      • Investigation
      • Communication
      • Methodology
      • Information sharing

    By Patient Safety Learning, 15 February, 2024

    • 0 comments
    • 3,444 views
    • 
    • Added by Patient Safety Learning
    • 15 February, 2024

21. Care Quality Commission: What you must do when you discover a notifiable safety incident (duty of candour) (last updated 22 December 2022)

    • Duty of Candour
    • Patient safety incident
    • (and 3 more)

      Tagged with:

      • Duty of Candour
      • Patient safety incident
      • Patient engagement
      • Transparency
      • Regulatory issue

    By Patient Safety Learning, 3 February, 2024

    • 0 comments
    • 352 views
    • 
    • Added by Patient Safety Learning
    • 3 February, 2024

22. The investigator's toolkit: SEIPS (HSSIB, 17 January 2024)

    • PSIRF
    • Investigation
    • (and 2 more)

      Tagged with:

      • PSIRF
      • Investigation
      • Patient safety incident
      • Methodology

    By Patient Safety Learning, 18 January, 2024

    • 0 comments
    • 1,493 views
    • 
    • Added by Patient Safety Learning
    • 18 January, 2024

23. Investigative approaches: Lessons learned from the RaDonda Vaught case (27 August 2023)

    • Investigation
    • PSIRF
    • (and 7 more)

      Tagged with:

      • Investigation
      • PSIRF
      • Human factors
      • System safety
      • Reporting
      • Safety process
      • USA
      • Legal issue
      • Patient death

    By Patient-Safety-Learning, 13 September, 2023

    • 0 comments
    • 2,104 views
    • 
    • Added by Patient-Safety-Learning
    • 13 September, 2023

24. Undertaking mortality case record reviews policy and procedure (14 September 2020)

    • Patient death
    • Investigation
    • (and 3 more)

      Tagged with:

      • Patient death
      • Investigation
      • Patient / family support
      • Harmed Care Pathway
      • England

    By Patient-Safety-Learning, 10 July, 2023

    • 0 comments
    • 690 views
    • 
    • Added by Patient-Safety-Learning
    • 10 July, 2023

25. NHS England podcast: Machine learning and LFPSE – revolutionising how we learn from patient safety events

    • PSIRF
    • LFPSE
    • (and 3 more)

      Tagged with:

      • PSIRF
      • LFPSE
      • Technology
      • Organisational learning
      • Patient safety incident

    By Patient Safety Learning, 16 June, 2023

    • 0 comments
    • 872 views
    • 
    • Added by Patient Safety Learning
    • 16 June, 2023