This Care Quality Commission (CQC) briefing document discusses the need for a change in the way that serious incidents are investigated and managed in the NHS. It is based on the findings of a review of a sample of serious incident investigation reports from 24 acute hospital trusts. This sample represented 15% of the total 159 acute hospital trusts in England at the time of review.
The briefing provides a summary of the findings, linked to five opportunities for improvement and calls for all organisations to work together across the system to align expectations and create the right environment for open reporting, learning and improvement.
Five opportunities for learning:
- Serious incidents that require full investigation should be prioritised and alternative methods for managing and learning from other types of incident should be developed.
- Patients and families should be routinely involved in investigations.
- Staff involved in the incident and investigation process should be engaged and supported.
- 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.