Case study 1: Involving patients in safety investigations
Global State of Patient Safety 2023
Country where the case study originated highlighted in red. Where relevant, additional countries where this programme has been implemented are highlighted in blue.
What is it?
The Learn Together project aimed to develop guidance to ensure more meaningful involvement in the investigation of serious healthcare incidents. The idea was that, by working relationally between patients, families and staff, the likelihood of compounded harm – where the harm relating to a patient safety event is compounded by the processes that follow it – is reduced.
A series of resources, free to download, have been designed for patients and families, and those investigating safety incidents, based on a set of common principles co-developed with these groups. These include a guide providing support for patients and families going through the process of a safety investigation, which includes space for patients and families to record key information about the investigation. Additional resources include a guide for investigators, as well as videos and links to other support and resources.
The first version of the resources focused on the procedural steps in a safety investigation, but following tests in real investigations, the final versions place more emphasis on the “relational touchpoints” that are necessary in the beginning of the investigation process, so that patients and families know what to expect and can have a say in how they would like to be involved.
Why was it developed?
Investigations can be made less daunting for patients, families and staff, and improve organisational learning, by listening to and valuing different perspectives. Part of this is around listening to patients and families, because:
“…they give us information that we don’t have from other sources… they will tell you important things about their experience. And they're the only person that will have been there across all their journey.”
However, through the process of developing the resources, the team has understood that the sense of healing and repair that can come from a safety investigation is just as important as the organisational learning that comes from it:
“Restoring trust in the health service is as important as anything else… that’s a public health issue, because if you lose trust in health services, you’re less likely to visit your GP next time you have a problem, or you’re not going to seek support from the community midwives if you have a problem with the maternity service”.
How can it be adopted?
The approach can be best described as following a set of five stages underpinned by a set of principles for working relationally, rather than a precise set of instructions, whether that is at a provider level or a system level. For example, the investigator guide includes some principles for working relationally. This means that the approach can be applied to different types of responses to safety incidents, not simply formal investigations, and to different types of contexts:
“What’s interesting in terms of this being a global activity… if you look at Canada, and New Zealand, and now Australia, they’re much more embracing of this notion of reparation and restoration… So, for me, it's been trying to take stuff from over there, which is brilliant and exciting stuff from different places and put it into the language and the possibility of the NHS.”
How can the measurement of patient safety be improved?
In future, the team is planning to carry out further work to better understand what organisations can do to support implementation of this approach to investigation, and therefore capture patient-centred insights about harm. While an organisation may introduce it as a new policy, staff still need to feel safe to put it into practice:
“People are really signed up to the moral arguments of it, but they’re still really nervous…. The whole thing is steeped in defensiveness. The policy might say, ‘you’re free to do things in this way’, but their experience is still, ‘if I don’t do this or that, the [regulator] or commissioner is going to come and ask why’… because for long periods of time, there’s been penalties for not meeting certain things, or doing certain things.”
Key resources and contact details
Learn Together - Serious Incident Investigation Resources
Professor Jane O'Hara: J.O'Hara@leeds.ac.uk
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