Risk controls identified in action plans following Serious Incident Investigations in secondary care: A qualitative study (26 June 2024)

Summary

The impact of incident investigations in improving patient safety may be linked to the quality of risk controls recommended in investigation reports. This study in the Journal of Patient Safety aimed to identify the range and apparent strength of risk controls generated from investigations into serious incidents, map them against contributory factors identified in investigation reports, and characterise the nature of the risk controls proposed.

The authors did a content analysis of 126 action plans of serious incident investigation reports from a multisite and multi-speciality UK hospital over a three-year period to identify the risk controls proposed. They found that:

• a substantial proportion (15%) of factors identified in investigation reports as contributing to serious incidents were not addressed by identifiable risk controls.
• most of the proposed risk controls in action plans were assessed as weak, typically focusing on individualised interventions, even when the problems were organisational or systemic in character.

They identified six broad approaches to risk controls:

1. improving individual or team performance
2. defining, standardising or reinforcing expected practice
3. improving the working environment
4. improving communication
5. process improvements
6. disciplinary actions.

The authors concluded that advancing the quality of risk controls after serious incident investigations requires involvement of human factors specialists in their design, a theory-of-change approach, evaluation, and curation and sharing of learning. This should be supported by a common framework.