Investigating serious incidents
The draft Health Service Safety Investigations Bill aims to bring about a whole-system change to how the NHS investigates and learns from investigating serious incidents. A learning culture in the airline industry has led to dramatic improvements in safety and it is this philosophy that is driving the draft investigations bill. Building on the Healthcare Safety Investigation Branch that has been in operation since April 2017, the bill will create a statutory Health Service Safety Investigations Body, independent of the NHS and at arm’s length from government.
The independent Health Service Safety Investigations Body will investigate for the sole purpose of learning, not to attribute blame or individual fault, providing a safe space for staff and patients to be open and candid when things go wrong.
The concept of investigating serious incidents within an open and fair culture is not new. Seven steps to patient safety reference guide was published by the National Patient Safety Agency in 2004. It promoted a systematic approach to incident investigation and recognised that a systems approach to safety acknowledges that the causes of patient safety incidents can’t just be linked to the actions of the individual healthcare staff involved. All incidents need to be linked to the system in which the individuals are working.
This is not to say that individual healthcare staff aren’t accountable for their actions, but an open and fair approach acknowledges the role of the trust to make sure that systems and processes are in place. These systems should provide a safety net to make it easy for staff to do the right thing, rather than have weak systems and processes in place which inadvertently set up staff to make mistakes.
The problem with this approach is that there is often no real learning so the same type of incident happens again.
I promote the idea of an open and fair approach to incident investigation at the Verita CPD accredited systematic incident investigation training. However, I hear many personal experiences from skilled and experienced staff being blamed and disciplined for making mistakes and errors whilst working within difficult and complex environments.
Perhaps the Health Service Safety Investigations Body can do what others haven’t been able to so far and finally shift the culture so there is a systematic approach to incident investigation within an open and fair culture that really makes a difference.