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In this Substack post, journalist Rory Cellan-Jones looks at a privately-funded project that aimed to give patients a better idea of how safe different hospitals were—the Good Hospital Guide. He speaks to Alex Kafetz, who worked on the Good Hospital Guide over a decade ago and was also a witness at the Mid Staffs inquiry in 2013. The project spotted and alerted Stafford Hospital to its high adjusted mortality rate ahead of the scandal, but the hospital rejected its data and findings. The Good Hospital Guide project was discontinued after its parent company was taken over, and nothing like it has been developed since, in spite of its success in identifying data patterns that indicated patient safety issues. Rory also highlights the lack of accessible data about hospital performance and mortality rates available to patients and highlights the need for making its data more accessible and transparent.

The 2024 BD Healthcare Resilience Barometer is a comprehensive analysis conducted by BD. It sets out to explore the resilience of healthcare systems in 100 countries across Europe, the Middle East, and Africa (EMEA) and is based on several healthcare-related indicators. Alongside a ranking and a healthcare resilience score per country, the BD Healthcare Resilience Barometer also highlights the perspectives of multiple key opinion leaders to help contextualise the barometer scores and bring unique insights into what can drive or threaten the resilience of healthcare systems, now and in the future.

This Strategy is based on a vision of Finland being a model country for client and patient safety in 2026. It is divided into four strategic priorities, each of which have three corresponding objectives aimed at strengthening patient safety. It is accompanied by an Implementation Plan so that these objectives can be translated into everyday activities. It was published by the Finnish Ministry of Social Affairs and Health, supported by preparatory work by the Finnish Centre for Client and Patient Safety. Below is a summary of the strategic priorities and objectives contained in this Strategy: Strategic priority 1 - Together with clients and patient Increase engagement to improve safety Promote client safety and patient safety side by side Experiences of clients, patients and close ones guide our service development Strategic priority 2 - Thriving and competent professionals Ensure safety competence and its development throughout careers Create safety by supporting wellbeing at work Improve safety through active leadership Strategic priority 3 - Safety first in all organisations Open data and information guide our actions and increase safety Ensure safe remote and digital services Safety culture is the foundation of our daily work Strategic priority 4 - Enhanced best practices Increase medication safety through common practices Ensure the safe use of medical devices and information systems Harmonise good practices in infection prevention and control The Strategy states that progress against these priorities and objectives will be monitored by the following ten key indicators: Service organisers are committed to implementing the objectives of the national Client and Patient Safety Strategy in their own strategies and action plans. Service providers have adopted hotline indicators of Never Events as part of their monitoring system. The incidence of healthcare-associated infections (HCAIs) shows a downward trend. The number of medication-related harm shows a downward trend. Cooperation models have been created between client and patient representatives and service providers and service unit leaders. The contents of the WHO Patient Safety Curriculum are included in the basic training of all healthcare and social welfare professionals. National development work has been launched to increase safety and wellbeing at work among healthcare and social welfare staff. The reporting and learning procedure for safety incidents has been reformed to meet the needs of a changing service system in terms of content and it has been integrated as part of service organisers’ information systems. Monitoring reports on client and patient safety are published annually at the national level and in the wellbeing services counties. Networks promoting client and patient safety cover all stakeholders and geographically the whole country.

Patient safety remains one of the most pressing health issues for public awareness and further policy action. Since 2006, OECD’s Health Care Quality and Outcomes (HCQO) Working Party (WP) has developed patient safety indicators (PSIs) based on administrative data sources. These data have been regularly collected and reported with an aim of assessing and comparing cross-country differences in patient safety. However, the international comparability of existing PSIs is challenging due to a number of methodological variations in measure implementation, for example, how countries record diagnoses and procedures, define hospital admissions, processes for reporting safety events. Consequently, in some cases, higher adverse event rates may signal more developed patient safety monitoring systems and a stronger patient safety culture rather than worse care. Current PSIs have limitations in that they fail to adequately capture important aspects of patient safety, such as the extent to which health care practices to prevent and address safety incidents are implemented.  This report summarises activities undertaken to date as part of the international indicator development on patient-reported experiences of safety and also a set of questions to be used for the pilot data collection of patient-reported experience of safety, guidelines for the pilot data collection and ongoing pilot data collection

This analysis by the Organisation for Economic Co-operation and Development provides the latest comparable data and trends on the performance of health systems in OECD countries and key emerging economies. It examines performance indicators that suggest the following trends: Overall health status in the United Kingdom is close to the OECD average Overweight/obesity and alcohol consumption are higher than the OECD average  Population coverage is high, with high satisfaction and strong financial protection The United Kingdom performs well on many key indicators of care quality, though avoidable hospital admissions could be further reduced Health and long-term care spending are above average, though hospital beds and the number of doctors and nurses are slightly below the OECD average The analysis also looks at the impact of the Covid-19 pandemic on deaths, health spending, life expectancy, healthcare activity and mental health.

The 2008 Second Global Patient Safety Challenge sponsored by the World Health Organization articulated 10 “essential objectives for safe surgery”. One of these is to “establish routine surveillance of surgical capacity, volume, and results” at the hospital level. There can be little doubt that this recommendation was made in the expectation that longitudinal surveillance and analysis of surgical results could lead to quality improvements in care and improved patient outcomes. In this linked study, Duclos and colleagues investigated a surveillance system the central feature of which was the use of Shewhart control charts. Originally developed to monitor industrial processes, control charts track variability in key process indicators over time and provide visual feedback on both positive and negative trends. This allows evaluation of the impact of process changes or, in the case of a negative trend, it triggers investigation into the causes and the formulation of appropriate responses. They found that the implementation of control charts with feedback on indicators to surgical teams was associated with concomitant reductions in major adverse events in patients. Understanding variations in surgical outcomes and how to provide safe surgery is imperative for improvements.

The World Health Organization (WHO) works worldwide to promote health, keep the world safe, and serve the vulnerable. Their goal is to ensure that a billion more people have universal health coverage, to protect a billion more people from health emergencies, and provide a further billion people with better health and well-being. The WHO has published ten patient safety facts, also highlighted in the attached infographic.

This is part two of a series about the investigation process and human factors in healthcare. Part one looked at the why we investigate an ‘incident’ and concluded that there is only one reason to investigate – and that’s to stop the error occurring again. The idea that human factors is a science – done by science types rather than by (deep breath) public speakers, non-technical skills (NTS) professionals, those who create team talks, medics who have been on a course about being nice and polite to other medics, and those that have married a human therefore they must be qualified to talk about humans – was also discussed. This and the next blog will introduce the concept of where facts or data comes from. Later blogs will deal with the who, how, when etc. The ‘who’ investigates (next blog) really is determined by where the facts come from. Later – if the cake lasts – we can chat about what to do with the data, and how to report it and save lives. Mummy – Where do facts come from? Well dear, when two investigators love each other very much (well can tolerate each other’s company for long periods of time) they do an investigation and the product is facts. Like a small child these facts bring great happiness, sadness and often inconvenient truths! These facts are messy – difficult to rationalise, have a life of their own, and will be tested by others in what appears to be out of context tests and exams. When the facts are older, both investigators will realise that they should not have been collected in the way they were. By then the investigators have made other facts that may be different from the first ones. We need facts in order to say what happened, write a report and stop the incident re-occurring – but what sources of facts and evidence is there that are relevant? In this section, I’ll discuss some sources outside the patient’s hospital records, test results, and the paperwork of the ward and theatre. The audience will know what all these records are and for brevity I will not go into detail. Moreover, is there a method or position in which facts are best collected that is rewarding and satisfying (to the regulator or other parties)? Perhaps that’s another blog? If we understand where facts come from this determines who (what sort of person) should collect them. Like many things, collecting facts by yourself is not as rewarding as doing it with others. I can already hear a deep sigh as a nurse is reading this thinking – others – did he say others? – well it’s just me and I’ve 40 to do by the time I go home. With emotions raised about the next piece, let’s think about the sources of facts an investigation will collect, then the method or structure to collect them. Ideally, we should talk about presentation of the facts and how they are displayed and shown off to others – look at my facts here, are they not clever? But let’s do that in the three E’s blog later. People – facts come from those present at the time Most of the evidence comes from those present or with some knowledge of the incident. Collection can be by interview, statement (oral and written), simulation... well loads of methods that try and recover a memory of an event, in the past, hiding in the mind. Noting here that humans are not video recorders and their memory is highly reconstructive and the worse creature on the planet to be a witness is a human. Humans also make terrible investigators, as they have biases and heuristics (more later when we chat about thinking and deciding in the human factors blogs). Interviewing witnesses is a skilled job but there are tools, techniques and methods that get ‘facts’ from inside someone’s head out onto your note pad – or recording device. There are three types of witness. Firstly, the person directly responsible (or who says they are responsible), there are those that directly observed the person who says they ‘did it’ and there are those who possibly noticed other useful facts – the security guard who noticed the arrival time, the HR person who interviewed the person the week before. Care needs to be taken if there is a chance of a criminal investigation, as the last thing the team needs is someone doing interviews that change the facts. Remember these posts are about prevention – not about criminal and civil liability matters. The tools and techniques tend to involve things like the Cognitive Interview. There are resources around that can help. There is an old NHS one – which hopefully has disappeared (by me ripping the leaflets up with my teeth) that says you ask the person to imagine the incident from another perspective. This of course we now know is the last thing to do. There are many blogs and posts I could write about the how to do an interview but look for a cognitive psychologist – PhD sort who does this area of memory research. From science and previous incidents – books and Professor Google The incident or one similar would have occurred before. This means there is a court record of it or a lovely science type has written a paper about it. Now hanging my head in shame, us science types don’t write in peer-reviewed journal articles in an easy to understand way. But all us science types love people asking about our work. Rather like the spotty kid at the school dance – we won’t make eye contact, but if you ask us about what we are interested in, well there is no shutting us up. Email saying I would like a copy of your paper to the spotty – I mean science type - is what you do. My team – who do the real work and have the titles of Professor and have lots of chartered words on their businesses cards – also stress that you need to, and I quote “and ask them to explain anything you don't understand" – they love that and it means you're not making any incorrect assumptions. Data and engineering logs Equipment when it fails tends to output data that is recoverable. The train I’m working on now records data every 1/25 of a second on every one of the driver inputs. In aviation, the flight recorder or black box (its orange by the way) measures the voice recording as well. One day healthcare will be there. But ask the question of its maker, what data is stored? Equipment operator manuals and testing Equipment sometimes, and in healthcare very occasionally, has been tested by a human factors type – ask the maker for the testing. This gives you an idea of how the medics dealt (or attempted to overcome) with its idiosyncratic ways. It sometimes seems that medical equipment is designed without much rigour. CCTV Spending two years of my life looking at CCTV images of a door in Paris means I think there is some value to CCTV ,and my work for HM Government on the subject does reveal its damn useful in finding the context of the event. Top tip is that data goes from a server after 28 days – so it’s one of the things to get quickly. There are CCTV experts, but a good dose of common sense means you will get lots of facts from it. Super, I’ve alienated another group of experts! Photos Photos are your friend. Photos are useful in your final report and show things clearly. Now you are about to hear spinning forensic photographers. Yes, there are specialist courses on how to take pictures and what camera to use. But, here we go, a phone camera is all you need. If I’m found dead in an alley with witnesses saying there were camera flashes – then those who taught me the subject have read this. Pictures tell a story and collect evidence in more detail than a note pad. Perhaps one day I’ll do a conference presentation on the topic. But the top tip at this point is to have a measuring tape in any close up and tell a story with your images. More experts alienated. Expert evaluations Experts are useful. A human factors person is a must, but a medic from a similar discipline or someone from the Royal college is a great asset. Although I lectured in neuropharmacology for 15 years, I still always get an expert in this field to explain the detail. I choose this area as everyone I’ve asked has been brilliant. I start with "help me understand…". Simulation and reconstruction These are major sources of data. But three questions: Why are you simulating the real world in a simulator – when it’s (the real world) out there? What’s the fidelity of the world the simulator generates? Who are your test victims - I mean participants? Healthcare is the weirdest place for simulation and exists in a world of its own. If you want to understand the issues, go to your local simulation suite and simulate nothing – aka a patient with nothing wrong with them – see what happens. A fiver says there will be hundreds of medical conditions found. It’s unlikely the correct conclusion that the person is well and asleep will be found. The problem is that aviation uses simulators (therefore they must be great), but these replicate the simple world of flying – aka stay in the blue, avoid green and land on the grey bits. Healthcare is not a simple world, its complex and we don’t know all the factors that you need to replicate or simulate. Simulation is a useful data collection method when you use people who were not involved in the original event. But those participating in the exercise know something is going to go wrong and have not worked the hours the team in the incident involved would most likely have done. I confess that in one of my published papers on fatigue the simulation was only 12 minutes long. But simulator time is expensive, and the pubs open at 16.00. Was the simulation good? Was there ecological validity in what I was doing? Well its published and other scientists thought it was ok. Oh, ecological validity – what you simulate or measure in a lab has something to do with the real world! Measuring things and testing them This is where my rail, road and aviation stuff comes in – I’m not sure why, but we always seem to throw one bit of metal at another and measure what happens. I’ve closed the centre of Croydon one night and threw black and white cars at each other all night. I’ve closed a motorway, caused chaos, and then the only thing the police remembered about the whole thing was driving along the closed motorway looking for badgers. Apparently, I do BF (Badger Factors). In the autumn I’ve learnt that badgers like the warm road and have a nap on the tarmac. Badgers are heavy things and if you hit them at speed you have another investigation to do. Testing to destruction gives loads of data, but the question before doing it is: what data do I get? – and are the badgers safe afterwards? Conclusion Data, facts, and evidence are vital to the investigation – that’s why you do it – to get facts. But a simple change in method or just the use of one word in an interview will change your outcome. Mummy may have explained about how two investigators love each other lots – but there is always a bigger picture. Is there a method or procedure that’s good? Yes, but that’s for another blog. But a quick search about the police methods (SIO) and the road death investigation manual might get you ready. Read the other blogs in this series Why investigate? Part 1 Who should investigate? Part 3 Human factors – the scientific study of man in her built environment. Part 4 When to investigate? Part 5 How or Why. Part 6 Why investigate? Part 7 – The questions and answers Why investigate? Part 8 – Why an ‘It’s an error trap conclusion’ is an error trap Why investigate? Part 9: Making wrong decisions when we think they are the right decisions Why investigate? Part 10: Fatigue – Enter the Sandman Why investigate? Part 11: We have a situation Why investigate? Part 12: Ethics in research

Guys and St Thomas' Hospital NHS Foundation Trust and the National Institute for Health research (NIHR) have developed an app. This app can be accessed by everyone. It will map out symptoms you may have (coronavirus symptoms) even if you feel well. This is part of ongoing research in how this virus is spreading and to understand symptoms. Take 1-minute to self-report daily, even if you are well. Help scientists identify: high-risk areas in the UK who is most at risk, by better understanding symptoms linked to underlying health conditions how fast the virus is spreading in your area.

Part 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. Let's start with a summary of where we are in the blogs. I’m told our reader likes the summary (a Mrs Trellis of North Wales). In part one we decided why we investigate an incident and what an incident was. In part two we decided that two investigators (or more) collect facts together in a more accurate way than one would. In part three we gazed into each other’s eyes and concluded that facts are our friends and where they might come from. We decided interviews and photos give us good facts. In part four we were introduced to what human factors is, and what it is all about and how western psychology is about exploiting the worker! In part five we thought that facts are time dependent and men of my age should not wear shorts outside a restaurant/come damaged aircraft. We discussed how dependent witness memories are on the elapsed time for the effective retrieval of information. These blogs, therefore, are asking simple investigation questions of Who, What, When and Why, and basic questions about what can humans do (human factors). So here we are back to the powerful question ‘Why’ but this time, rather than "why investigate an event?", we are asking "why did this event happen?". Most investigations stop at the point of understanding how the person was injured or died. The how they died does not give you enough data to prevent it occurring again. Knowing, for example, that an elderly, lone rail passenger unfamiliar with the station died from head injuries after falling on a platform with the investigation team concluding that ‘they lost their balance and fell backwards’ does not help understand why this happened or how to prevent its reoccurrence. Why did it occur that day, to that person, on that platform? Might an intervention based on the question ‘How’ be that no one over 60, who is unfamiliar with the station and travelling alone, be prohibited from travel. The important question is why and not how. Likewise, a pedestrian is found dead by the side of the road after a collision with a van. How did they die? Well head trauma after collision with a van. How did that occur? The driver said that at night it was too dark to see the running pedestrian. Indeed, at the reconstruction it was very dark. But after 25 questions of ‘why’ came the critical ones. Why was a person out running in near total darkness without a light? Why could the van driver not see them? Why was there no light (torch etc) found with the pedestrian so they could run without falling into the numerous pot holes? Why that van and why that pedestrian. The why (in this case) comes from human factors research into perceptual thresholds of how much light needs to hit the retina for the cognitive process to start. Long story, but the answer to why was a murder disguised as a traffic accident. Which takes us back to my first blog – what’s an accident – this was not a rare random event with multiple causes. It had one cause – top tip sleeping with a colleague’s partner is not a good idea. Unless you answer why, then there is no intervention and that ‘why’ is ‘why’ we do this. Becoming a 5-year-old The skill of an investigator in human factors is to keep asking the question Why (and perhaps not to insist an infographic is needed). Like my 5-year-old self. Why can’t I ride my bike to the next town… But why, but why. The police car brought me back last time – I was not lost. This may explain why a disproportionate number of my friends are clinical psychologists! Case studies Two case studies. Let’s stick to rail. I can do why are anaesthetics rooms so small, but I’ll get all emotional! If I’m found dead in an alley it’s a hospital facilities manager wot did it. Case One A train station where there are 17 serious incidents on a single set of steps down to platform 1. It’s a traditional Victorian design urban station with access at street level and platforms below the booking hall. All platforms are connected by a glass overpass. No other platform (there are six) has an issue. One case is a fatality. How did they occur? The answer is – the person fell down the stairs. Head injuries and broken legs (not the same person!) are common. The ‘how ‘is answered. The why is not. Why did they fall down the stairs we asked. “There are stairs and people will fall down them” came the reply. Why? “Well there are stairs and people will fall down them”. But why these stairs, why this platform, and why 17 people? Well, came the reply, we will have to put a poster up telling people ‘these are stairs.’ Why did they fall we asked? We have a poster telling people how not to fall down them and how to use stairs (hold the handrail) they replied. We asked as a five-year-old would – why do you think these people have problems with these stairs? So, let’s think of the why questions after some facts. Might be worth also predicting that posters are the sign of defeat and result from only asking ‘how’. Also, putting posters above stairs, so that people look at them and not the stairs, is another classic failure of understanding human performance. Some facts Timetable information shows platform 1 is the city bound platform. Observations indicate that people descend the stairs very rapidly when there is a train present at the platform. Secondary observations come to understand that running starts at the ticket office overlooking the glass passageway over to the platform. Incident data reveals peak at rush hour above that of exposure (rise in passenger numbers). Only platform 1 can been seen from the walkway and the ticket office. The ‘why’ hypotheses was that as people became aware of the train arriving at the city bound platform, they made a run for it. We interviewed several of those injured. Most common statement from the predominantly local people was “I knew I would miss the train as I could see it at the platform, so I ran”. The remedy was to put plastic obscuring film over the glass walkway so you could not see if a train was at the platform. No cognisance of a train’s presence = no rapid stair descents. Only journeys into the city appear to be highly time dependent. Outcome After 11 years, no incidents on the stairs, no aggression to the ticket office staff (give me my ticket now!) and posters removed. Why – we asked ‘why’ not ‘how’. Removing ‘safety’ posters is always a good idea. I’m still trying to find out what an internal brand consultant is – they were against the removal of posters. Answers if you know what these are and how they make the world better please. Case 2 At a train station, there were 27 falls ‘down the steps’ of which four were citizens from the USA. These citizens of America are after the compensation for ‘foreseeable’ injury in the US courts. Think expensive when compared to compensation claims in the UK. As above, ‘the how’ was they were injured by a fall. Why at this station? Why these people? Some facts Incident data revealed all those falling down the stairs were visitors to the area (based on address supplied). Plans of the Victorian station reveals it’s a small (four platform station) with over 80 different exit route combinations, via three underpasses. Exit here is time-critical – it’s near an airport with a connecting bus. There are over 130 signs containing over 900 words of advice. Observations and interviews showed that perhaps passengers lost spatial and situational awareness (more in later blogs) and became disoriented. CCTV images showed one passenger was walking up and down the platform twice, then walking through one of the underpasses six times, before they injured their arm when the bag got caught in the handrail and they ‘went down, way down, the steps’ ( from Incident report). Our initial hypothesis was that a lost and disoriented passenger with bags will find stairs more of a challenge than one who is not. Remedy We removed most of the signs on the platforms and underpasses and replaced with one type of exit sign. Whether its exit to the airport or exit to the pub it’s still an exit. Locals – not represented at all in the data – know which of the combination of exits will get them to the pub. Outcome No incidents in 12 years, and the platform staff last year took rail executives around ‘their’ station telling them how easy it was to prevent slips, trips and falls because “someone asked why”. Why, and multiple causes Early on in our blog life together we said that accidents have multiple causes. In healthcare we are not sure how many variables there are and even the extent of the problem. We also described that the cause is about the ‘environment’, the ‘human’, the ‘system of working’ or the ‘equipment’. We decided together this determines ‘who should investigate’. Engineering failings are done by engineers, for systems failures investigations by nursing staff are recommended. Well here the ‘Why' word repeated on the first day is the solution to find out who should investigate. When do you know you have possibly stopped asking why too early? The common reasons for stopping asking the question ‘why’ is when you get to one of the following conclusions: 1. Its human error. 2. It’s the person who had the incidents fault – but remember organisations fail not people. If you get these conclusions, keep going and ask your friendly human factors person for help. Remember, one of the limits of investigations is that you can’t ask questions about things you don’t know about – obvious really, but that’s why there should be two of you and perhaps one of those is a human factors person. A major failing in root cause analysis is this fact is always overlooked. 3. I cannot ask ‘why’ anymore without getting asked to leave the building/the NHS/the human race… The solution is to ask questions using the Socratic method. More later when we think about logic – but the Greek philosophy types nailed it many centuries ago (just like they invented human factors in medicine; ergonomics they called it). Citing Professor Wiki once more and to appeal to the midwifes among you, the Socratic method is: “a form of cooperative argumentative dialogue between individuals, based on asking and answering questions to stimulate critical thinking and to draw out ideas and underlying presuppositions. It is named after the Classical Greek philosopher Socrates and is introduced by him in Plato's Theaetetus as midwifery (maieutic) because it is employed to bring out definitions implicit in the interlocutors' beliefs, or to help them further their understanding”. Again, this is part of the human factors persons training and why we ask the questions in the way we do to members of the investigation team (sorry). There is a management consultancy (boo hiss) methodology called the ‘5 why method’, and its creeps into the root cause analysis nonsense (more boos). But just asking why without the Socratic teachings tends to just annoy people. Exploring ‘Why’ as an equal to the person you are talking to is more respectful and gets better data, and you should not get thumped. Who asks why and to whom? In later blogs we shall chat about interviewing witnesses. This blog is about the internal dialogue in the investigation team or, if there is just one of you, the internal monologue. Asking why to a witness is generally not the thing to do. Its common in healthcare but the witness cannot report Why, they only know the How. Witnesses provide facts, the team finds answers from those facts ('Where do facts come from?'). Summary The ‘Why’ word is very powerful when added to a blank sheet of paper and a pen in the hand of the investigator and means that you focus on the outcome and not on a process. As replies to my earlier blogs – about how healthcare is all about process and not outcomes – well one word and some paper mean you can just focus on prevention. And dear reader why we investigate is to prevent it occurring – in the words of Metallica – 'Nothing else matters'. And finally... The station (discussed above) where elderly people represent the dataset. All falling backwards on platform 1 and our initial (yours and mine dear reader) remedy was to exclude over 60s from it unless they were trained. Suggestions of why and what questions would you ask. Comments below. (See Why investigate? Part 7 for the answer.) Follow 0 Posted by MartinL Top tip – no one was running and all very cognisant of the train times, and all but one sober. Happy if you want to test out the Socratic method now. Posters, as a solution, are not permitted. Read the other blogs in this series Why investigate? Part 1 Why investigate? Part 2: Where do facts come from (mummy)? Who should investigate? Part 3 Human factors – the scientific study of man in her built environment. Part 4 When to investigate? Part 5 Why investigate? Part 7 – The questions and answers Why investigate? Part 9: Making wrong decisions when we think they are the right decisions Why investigate? Part 10: Fatigue – Enter the Sandman Why investigate? Part 11: We have a situation Why investigate? Part 12: Ethics in research

The Patient Safety Indicators (PSIs) are a set of quality indicators developed by the Agency for Healthcare Research and Quality (AHRQ) providing information on potential hospital complications and adverse events after surgeries, procedures, and childbirth. They have been used for the past two decades in the USA for monitoring potentially preventable patient safety events in the inpatient setting through the automated screening of readily available administrative data. However, these indicators are also used for hospital benchmarking and cross-country comparisons in other nations with different health-care settings and coding systems as well as missing present on admission (POA) flags in the administrative data. This study sought to comprehensively assess and compare the validity of 16 PSIs in Switzerland, where they have not been previously applied.

The Patient Safety Indicators (PSIs) provide information on potentially avoidable safety events that represent opportunities for improvement in the delivery of care. More specifically, they focus on potential in-hospital complications and adverse events following surgeries, procedures, and childbirth. You can find out more about PSIs and access related resources, on the Agency for Healthcare Research and Quality (AHRQ) website via the link below.