At Verita, we understand that investigating serious incidents is crucial for organisational learning to take place. Investigators need to ensure that they get to the bottom of the real underlying problems, rather than just focusing on mistakes made at the sharp end. This approach will make sure that useful recommendations will address any systems issues.
Poor investigations into serious incidents only miss opportunities to make services safer but can lead to heavyweight scrutiny, reputational damage, and costly legal claims. With healthcare’s growing focus on investigations, we were curious to find out the perspective of the front-line users.
In a Twitter poll carried out last week, we asked healthcare staff if they felt adequately trained to carry out serious incident investigations. Over 1,000 people responded and out of the 50 per cent who said they needed training, 29% felt their training was outdated or left them feeling apprehensive about carrying out an investigation. Whilst it is promising that 21% of respondents are confident with their training, it suggests that further support and training is needed.
One respondent commented:
Where’s the option for “I’ve had some training but I’ve got 37 other people to see today, so I haven’t got time, and nothing will come off it anyhow so I’ll just carry on and hope for the best.”
What these responses show is that training is necessary and valued, however, time pressures and support from senior leadership create an area of doubt. Stating that ‘nothing will come off it anyhow so I’ll just carry on and hope for the best’ suggests that investigations can be seen as a burden amongst a busy schedule. It is important to patients, staff and organisations that investigations are carried out properly so that future harm is avoided. Any recommendations made need to address the problem and improve services. This can only happen if investigations are of high quality, that those carrying out investigations are competent and that they are supported by senior leadership.
Our trainers are experienced in delivering serious incident reviews so they fully understand the complexities involved in carrying out a successful investigation in a demanding environment. One of the most popular aspects of our training focuses on human characteristics and behaviour which is so often, and in so many ways, the difference between success and catastrophe.
Our Twitter poll ran for 7 days and received 1,228 votes. We asked the question:
As a member of staff in healthcare, does your employer provide adequate training for you to carry out investigations into serious incidents?
21% Yes, I have had training
15% Yes but I’m not confident
14% Yes but it’s now outdated
50% No I haven’t had training