Dear hub members
We've a request to help from New South Wales. They and their RLDatix colleagues request:
The public healthcare system in New South Wales (NSW), Australia is changing how we investigate health care incidents. We are aiming to add to our armoury of investigation methods for serious clinical incidents and would love to hear your suggestions. Like many health care settings worldwide, in NSW we have solely used Root Cause Analysis (RCA) for over 15 years. We are looking for alternate investigation methods to complement RCA. So we are putting the call out …
Are there other serious incident investigation methods (other than RCAs) you would recommend? What’s been your experience with introducing and/or using these methods? Do you have learnings, data or resources that you could share? Do you have policy or procedure documents about specific methods? Any journal articles – health care or otherwise – that are must-reads?
We've many resources on investigations on the hub and recent thinking in the UK and internationally that might be of value including:
UK Parliamentary report - Investigating clinical incidents in the NHS and from that the creation of
A Healthcare Safety Investigation Branch applying a wide range of methodologies in national learning investigations informed by ergonomics and human factors
UK's NHS Improvement recent engagement on a new Serious Incident Framework (due to piloted in early 2020)
Dr Helen Higham work with the AHSN team in Oxford to improve the quality of incident investigations
Patient engagement in investigations
Lessons to be learned from Inquiries into unsafe care and reflections on the quality of investigations
Insights by leading investigators and resources written specifically for us by inclusion our Expert Topic Lead @MartinL
Do check these out in this section of the hub https://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/
Please add to this knowledge and give us your reflections. We'd be happy to start up specific discussions on topics of interest.
Thank you all, Helen