Investigating Patient Safety Incidents

Investigating Patient Safety Incidents; collecting and collating data to facilitate effective Root Cause Analysis

The National Patient Safety Agency (NPSA) is promoting Root Cause Analysis (RCA) as a means of gaining organisational and national learning following a patient safety incident. To undertake robust root cause analysis comprehensive data is needed from a rigorous and searching investigation of an incident. Without such thoroughness it is not possible to extract lessons that will impact upon practice. A major failing in the investigation process is the lack of training provided for staff required to gather data following an incident.

Recent national reports find most incident investigation systems used by healthcare organisations are:

• Unidisciplinary
• Subjective
• Inconsistent
• Failing to inform the analysis process
• Focussed upon human failings rather than system failures
• Not facilitating changes in practice

This programme provides an overview of the methods and techniques used for investigating patient safety incidents. Participants will be made aware of the importance of ensuring investigation data is relevant, reliable and complies with legal requirements, particularly vital for incidents that ultimately lead to litigation or compensation claims.

Inadequate investigation of a patient safety incident will lead to a failure in identifying the true causal factors and so preclude opportunities for learning lessons and changing practice.

The course is interactive and draws on the participants knowledge, skills and experience, using case studies and simulation. It develops skills in a range of investigation techniques.

Participants will be equipped with the knowledge, skills and confidence to undertake deep, probing, robust and legally sound investigations into patient safety incidents.

Course participants will learn to:

• Classify incidents and determine the level of investigation required.
• Appoint appropriate investigators.
• Gather data.
• Ensure data/evidence meets legal requirements.
• Undertake multidisciplinary reviews.
• Identify causal factors and map information.
• Select relevant root cause analysis tools.
• Devise action plans and select relevant audit tools to monitor change.