Investigating patient safety incidents

Kate Woodhead RGN DMS provides an insight into efforts to apply learning from safety incidents, with a view to reducing avoidable deaths and changing the culture of blame within the National Health Service.

It was recently announced by the Secretary of State for Health, at the Global Patient Safety Summit, held in London, that the NHS would soon have an additional tool to assist in reducing some of the 150 avoidable deaths which occur in the NHS every week.1 The Department of Health is setting up an incident investigation organisation to assist Trusts. It will be named the Healthcare Safety Investigation Branch (HSIB) and is being modelled on the Aviation Industry’s Air Accident Investigation Branch. In announcing the HSIB, which will begin its work in April, Jeremy Hunt said that he aimed to make the NHS change its culture from a blame culture to one of being a learning organisation. 

Since the Francis Report reported on the tragic occurrences at Mid Staffordshire Hospitals, three years ago, much has been done to improve the safety culture in the hospitals in England.  There have been many activities on patient safety and a plethora of reports all focused on changing the culture, improving patient safety and developing a more transparent service for patients. Many of these activities have been reported within these pages, over the last several years.