NHS England Patient safety incident investigation tools

Summary

These tools and worksheets have been produced by NHS England to assist staff in conducting patient safety incident investigations. NHS England stresses that patient safety investigation is an important and complex task and should only be undertaken by those who have attended training and gained skills and experience from specialists in the field.

Content

PSII incident mapping worksheet
A template to assist in the compilation of a timeline/chronology of events leading up to a patient safety incident. A flowchart or a two-dimensional depiction of the work/task can add great value.

PSII contributory and mitigation factors classification
A taxonomy of key factors (including ergonomic and human factors), which underlie patient safety incidents.

PSII contributory, causal and mitigating factors analysis worksheet
A tool designed for use in conjunction with the contributory factors framework above, to guide and organise the analysis of interconnected, contributory, causal and mitigating factors

PSII change analysis tool
A template to identify and document variations to policy, protocol or expected practice (work as imagined). It is important to note that variations are common and are most often the result of efficiency-thoroughness trade-offs.

PSII nominal group technique tool
A template to prioritise problems and their further analysis.

PSII options appraisal and impact analysis tool
A tool to assess and compare the relative efficacy, value and cost of a range of solutions. This can be used either at the improvement development stage, or after the solutions/improvements have already been implemented.

Risk assessment tool
A tool to assess the likelihood and severity of identified hazards in order that risks can be determined, prioritised, and sensible control measures applied (eg clinical, safety, business risks).