HSIB’s local investigation pilot: shared learning for local healthcare systems
HSIB Legacy
Published
Analysis
Emergency care
A summary of findings from our local investigation pilot applicable to local healthcare systems.
1 recommendation
4 observations
2 learning prompts
Safety Recommendations (1)
The pilot investigations made safety recommendations to the local healthcare organisations. The aim of the safety recommendations was to highlight issues identified during the investigations that if addressed would reduce the risk of future, similar events occurring. It was not intended for safety recommendations to offer specific solutions.
Safety Observations (4)
It may be beneficial if local healthcare systems consider how best to support the investigation of cross-organisation safety events as they implement the Patient Safety Incident Response Framework.
It may be beneficial if national and regional bodies consider how healthcare organisations can be supported to develop effective systems-based solutions to identified patient safety risks.
It may be beneficial if healthcare organisations develop processes to identify safety improvement themes from patient safety investigation reports.
It may be beneficial if providers of NHS care consider low-harm and no-harm safety events as sources of learning in local patient safety incident response plans.
Learning Prompts (2)
HSIB national investigation ‘Harm caused by delays in transferring patients to the right place of care .’
HSIB national learning report ‘ Positive patient identification .’