Improving NHS investigation of patient safety incidents

Abstract

We discuss the deficiencies of current NHS patient safety investigation and specifically the need for independence and Human Factors training. We describe the theory behind a regional network approach to improving the quality of investigations, and the development of a pilot study. We report outcomes from the first three investigations and the learning gained from the experience of conducting the pilot study. We make recommendations for how this type of solution to the problem of adequate investigation could be further developed