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Content ArticleThis policy was written by Sussex Partnership NHS Foundation Trust. It is designed to ensure that concerns regarding the conduct or performance of staff which require formal investigation are investigated in a fair and consistent manner. Such an investigation may arise during the operation of other policies such as Dignity at Work, Grievance or Freedom to Speak Up. The outcome of the investigation may lead to further action such as a disciplinary hearing or use of the Managing Performance and Capability Policy. The policy identifies the circumstances in which an investigation will be necessary, the steps which should be taken in carrying out an investigation, the rights of staff during the process and potential outcomes.
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Content ArticleThe Parliamentary Healthcare Service Ombudsman published 'Ignoring the alarms: How NHS eating disorder services are failing patients' in December 2017. The families who brought forward their complaints helped uncover serious issues that required national attention. The failings catalogued in the report highlighted a systemic set of problems in relation to identifying, treating and monitoring eating disorders that require a systemic response. This encompasses raising awareness among clinicians, building greater specialist capability and ensuring adult eating disorder services achieve parity with child and adolescent services. This submission provides an overview of the report’s systemic findings and the responses seen to the systemic recommendations made to date.
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Content ArticleWritten by the safety team at Morecambe Bay Hospital NHS Trust. Introducing staff to the team, their governance hub, a new support system for staff involved in an investigation and what happens in an inquest by the legal team.
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Content ArticleCataract removal and implantation of an artificial lens is the most common surgical procedure undertaken by the NHS. Insertion of an incorrect intraocular lens was the most commonly reported never event in England between April 2016 and March 2017. A never event is a serious incident that is entirely preventable. Read the Healthcare Safety Investigation Branch's report on the insertion of an incorrect intraocular lens.
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Content ArticleBoth national and maternity investigations are showing a high level of family engagement through an inclusive and innovative model that ensures families have a voice throughout investigations. Here the Healthcare Safety Investigation Branch (HSIB) demonstrate how they involve families in their investigations.
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Content ArticleHealthcare Safety Investigation Branch (HSIB) report on the inadvertent administration of an oral liquid medicine into a vein. This report indicated the importance of using human factors in the investigation process. The investigation reviewed the effectiveness of the current processes for the storage of medicines, equipment design, and the prescribing, preparation, checking and administration of medication. It also considered the contextual, environmental and human factors that influenced the inadvertent administration of an oral solution into a vein. The effectiveness of current processes for implementation of local safety standards for invasive procedures was also considered. A human factors expert was involved in the investigation and a dedicated report was written based on the evidence reviewed, a reconstruction of the event and a simulation of what should have happened.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) launched an investigation following the referral of a case from an acute trust involving failure of oxygen delivery during a resuscitation. The case highlighted several issues related to the safe delivery of oxygen from portable systems.
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Content ArticleSome of the serious findings of external reviews of NHS services from recent years, previously unpublished, have been released to HSJ. An HSJ investigation has found the NHS has kept secret dozens of external reviews into care failings in local services including: A hospital where surgery may have “shortened life expectancy”. An alleged “cartel” of private patients said to be put on NHS lists. “Very high risk” consultant on-call arrangements. Problems with fetal heart monitoring in a maternity service. Potentially unnecessary operations being carried out. Rows among doctors putting patients at risk. Read their full report below.
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Content ArticleThe Chartered Institute of Ergonomics & Human Factors has issued today their White Paper on Adverse Events. This report states what good practice should be in incident investigation across all industries, including health and social care. The White Paper is designed to: 1. Help organisations understand a human factors perspective to investigating and learning from adverse events. 2. Provide key principles organisations can apply to capture the human contribution to adverse events. How organisations learn, and fail to learn, from adverse events is discussed.
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Content Article
Deaths in custody guidance
Claire Cox posted an article in Prison setting
The Crown Prosecution Service (CPS) prosecutes criminal cases that have been investigated by the police and other investigative organisations in England and Wales. The CPS is independent and make their decisions independently of the police and government. -
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Failure - is it a matter of when?
Claire Cox posted an article in Miscellaneous
'When problems occur we hunt for a single root cause, that one broken piece or person to hold accountable. Our analyses of complex system breakdowns remains linear, componential and reductive.' This is evident in healthcare. Barry O’Reilly is a business advisor, entrepreneur and author who has pioneered the intersection of business model innovation, product development, organisational design and culture transformation. In this blog he discusses the 'drift into failure', i.e. we had the warning signs but accepted them as the norm. -
Content ArticleIn accident investigation, the ideal is often to follow the principle “what-you-find-is-what-you-fix”, an ideal reflecting that the investigation should be a rational process of first identifying causes, and then implement remedial actions to fix them. Previous research has however identified cognitive and political biases leading away from this ideal. Somewhat surprisingly, however, the same factors that often are highlighted in modern accident models are not perceived in a recursive manner to reflect how they influence the process of accident investigation in itself. Those factors are more extensive than the cognitive and political biases that are often highlighted in theory. The purpose in this study from Lundberg et al. (published in Accident, Analysis and Prevention) was to reveal constraints affecting accident investigation practices that lead the investigation towards or away from the ideal of “what-you-find-is-what-you-fix”.
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Content ArticlePart 6 of this series of blogs about human factors and investigations in healthcare discusses the 'How' and the 'Why'. How did the person die or was injured is different from understanding why it happened? At first this appears to be a pedantic, minor issue, but, as (hopefully) we shall see from this blog, it’s a vital distinction. Question How did the plane crash? Answer It was hit by a missile. Question Why was a missile launched, is a vastly different question. Question How was it that the pedestrian was hit by the car? Answer It was due to the driver not seeing them – but why did they not see them is the question. Without the why – you can’t do the intervention. Most investigations done stop at the how – few get to the why, especially in medicine, especially with root cause analysis.
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Content ArticleROSPA's one-day accident investigation training will give you a broad understanding of the accident investigation process, looking at the benefits of accident prevention and putting the emphasis on practical training exercises and real-life case studies. Training is suitable for line managers, supervisors, safety representatives – and anyone with the responsibility for investigating accidents. It will enable organisations to meet their moral and legal obligations to investigate accidents and incidents and learn from safety failure.
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Content ArticleNEBOSH and Great Britain’s Health and Safety Regulator, the Health and Safety Executive (HSE), have jointly developed a new one day qualification that shows how non-complex incidents can be investigated effectively. By learning lessons and making improvements, organisations can avoid similar incidents occurring in the future.
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Content ArticlePatient and family involvement is high on the international quality and safety agenda. This paper, published in the International Journal for Quality in Health Care, considers possible ways of involving families in investigations of fatal adverse events and how their greater participation might improve the quality of investigations. There is limited guidance and research on how to constitute effective involvement. There is a need for co-designing the investigation process, explicitly agreeing the family’s level of involvement, supporting and preparing the family, providing easily accessible user-friendly language and using different methods of involvement (e.g. individual interviews, focus group interviews and questionnaires), depending on the family’s needs.
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Content ArticleJoanna is a Partner in the law firm Bevan Brittan LLP. In our interview, Joanna talks about her role supporting healthcare staff through the legal and investigatory processes that follow an adverse event, and why we must do all we can to maximise the opportunity to learn when things go wrong in healthcare.
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Content ArticleThis article, published by the British Medical Journal, argues that the NHS cannot afford to divert more and more money to litigation and we need to tackle the problem at source. Tim Draycott and colleagues set out four principles to reduce avoidable harm: Invest in staffing and infrastructure Really commit to learning Learn from high performance Enable and support system-wide safety improvements.
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Content ArticleThis is part 5 of a series of blogs about human factors and investigations in healthcare. The theme is ‘when’ and that covers ‘when’ to investigate and ‘when’ to try any remedies or interventions your investigation data suggests might prevent the incident occurring again. As this blog can be explained by a photo and a graph, we have some time to recap the story so far and, perhaps, predict a bit of the future.
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Content ArticleIn the past 15 years, healthcare has focused primarily on building the technical infrastructure for incident reporting systems: online reporting systems, data collection forms, categorisation schemes and analytical tools. These are all important foundations. But this focus on incident data is also the source of many of our current problems with incident reporting: we collect too much and do too little. Learning depends critically on the less visible social processes of inquiry, investigation and improvement that unfold around incidents. Over the next 15 years we must refocus our efforts and develop more sophisticated infrastructures for investigation, learning and sharing, to ensure that safety incidents are routinely transformed into system wide improvements.
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The problem with ‘5 whys’ (September 2017)
Claire Cox posted an article in Quality Improvement
‘The problem with…’ series, from the BMJ Quality & Safety, covers controversial topics related to efforts to improve healthcare quality, including widely recommended but deceptively difficult strategies for improvement and pervasive problems that seem to resist solution. The ‘5 whys’ technique is one of the most widely taught approaches to root-cause analysis (RCA) in healthcare. Its use is promoted by the WHO, the English National Health Service, the Institute for Healthcare Improvement, the Joint Commission and many other organisations in the field of healthcare quality and safety. Like most such tools, though, its popularity is not the result of any evidence that it is effective. This article argues that healthcare is complex and why finding the solution via the 5 whys should be abandoned. -
Content ArticleAmerican women visit more doctors, have more surgery, and fill more prescriptions than men. In Everything Below the Waist, Jennifer Block asks: why is the life expectancy of women today declining relative to women in other high-income countries and even relative to the generation before them? Block examines several staples of modern women's health care, from fertility technology to contraception to pelvic surgery to miscarriage treatment and finds that while over-diagnosis and over-treatment persist in medicine generally, they are particularly acute for women. Further reading: Interview with the author
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Content ArticleFourteen years after being diagnosed with endometriosis, Gabrielle Jackson couldn't believe how little had changed in the treatment and knowledge of the disease. In 2015, her personal story kick-started a worldwide investigation into the disease by the Guardian; thousands of women got in touch to tell their own stories and many more read and shared the material. What began as one issue led Jackson to explore how women, historically and through to the present day, are under-served by the systems that should keep them happy, healthy and informed about their bodies. Further reading: Interview with the author
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Content Article
Marking your own homework
Anonymous posted an article in Florence in the Machine
Having read the recent blog on the hub, ‘Silent witness’, this nurse too was compelled to share with us her frustrations on the current hospital reporting system.- Posted
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Content ArticleThis pay-walled article, published in The Sunday Times, highlights patient safety concerns identified in relation to West Suffolk hospital, with specific reference to two incidences of avoidable patient harm. In the case of Daniel Parsons, a drugs error caused an adverse affect on the functioning of Daniel's heart and led to his death. The coroner for the inquest concluded that Daniel's death could have been avoided if doctors had heeded the early warning signs of anaphylaxis. The second incident highlighted by the authors is that of Paul Farmer, who was left blind and with severe brain damage following avoidable harm. Concerns raised within the article include: Prioritisation of reputation management (an 'outstanding' status) over patient safety Reluctance to investigate Unfair reprisal for staff raising patient safety concerns Lack of response from Health Secretary Matt Hancock. Further reading: Bullying executives left West Suffolk Hospital staff ‘sobbing, shaking, rocking in despair’ (March 2020)
