Investigating for improvement? Five strategies to ensure national patient safety investigations improve patient safety

Abstract

Improving patient safety across entire healthcare systems remains an urgent and complex challenge. One important strategy for system-wide safety improvement involves investigating and addressing the system-wide sources of risk that contribute to unsafe care. Common types of safety incident – such as wrong site surgery or delayed diagnosis – can harm different patients in different places at different times, but often result from very similar circumstances and underlying problems. Equally, factors that contribute to unsafe care arise in many parts of the healthcare system: poor design of equipment; gaps in training; misguided regulatory incentives; inadequate funding; and much else besides. The healthcare systems of England and Norway are currently experimenting with a new and ambitious approach to address system-wide sources of risk. Both have created national, independent safety investigation bodies that will investigate serious patient safety risks that span the healthcare system and develop system-wide recommendations for learning and improvement. In England, the Healthcare Safety Investigation Branch became operational in April 2017, following proposals put forward in this journal. In Norway, the State Investigation Commission for Health and Care Services becomes operational in 2019. Independent, system-wide and learning-focused safety investigation bodies like these have long and successful histories in other safety-critical sectors such as aviation and the railways. But in healthcare, this is a relatively new and untested approach that faces significant challenges. Some of these challenges are social and cultural, such as building trust and maintaining independence. But many of the most immediate challenges are more practical and tangible: developing systems-focused investigation methods and safety analysis tools; establishing new approaches to designing impactful, influential and system-wide recommendations; and building new infrastructure to share findings and knowledge in ways that support the translation of recommendations into action. In addressing these challenges, these new investigation bodies have a unique opportunity to have a broad and meaningful impact on system-wide safety and to fundamentally reformulate how safety investigations are conducted across healthcare. To do this, five core strategies would seem particularly important in guiding the development of these new investigative organisations (Table 1). These strategies translate the fundamental principles of national, system-wide safety investigation into more concrete objectives for strategic development and draw on both early experiences in the English health system combined with insights from other learning-oriented, systems-focused investigative practices.