Effective Investigations

In a nutshell: In health care recognition that things go wrong and patents are harmed as a result is critical to making care safer. In the six months from October 2014 to March 2015, 825 416 incidents in England were reported. Effective investigation is essential to optimize learning and take action to prevent further similar incidents occurring.

Incident Reporting

Reporting an incident is just the first step in the process: reporting, investigation, learning, action planning, implementation and closure.

All health care staff have a duty to report when things go wrong or when near miss incidents occur. Reporting of incidents of all severity are important, serious incidents make up only a tiny proportion (less than 1% NRLS 2016). The vast majority result in no or low harm (71.2% and 23.9% respectively).

At a national level, patterns about the type of emerging incidents are fed into patient safety alerts; at a local level this information can support clinicians to learn about why patient safety incidents happen within their own service and organisation, and what they can do to keep their patients safe from avoidable harm.


Investigating Incidents

After an incident has been reported, a good organisation will recognise harm (and the potential for harm) and will undertake swift, thoughtful and practical action in response. It is important that individuals and not inappropriately blamed as doing so will discourage reporting, disincentivise information sharing and inhibit learning. The Incident Decision Tree is a useful tool to help you determine a fair and consistent course of action toward staff involved in patient safety incidents.

To truly understand why things go wrong it is key that the investigation is conducted in an open and transparent way (as described in 'Being Open') and conducted for the purposes of learning to prevent recurrence and not to hold any individual or organisation to account.

The NHS uses a multi-incident investigation root cause analysis (RCA) model to provide a useful tool for investigating reoccurring problems of a similar nature and serious incidents (for example, a cluster of falls or pressure ulcers in a similar setting or amongst similar groups of patients). This allows identification of the common problems (the what?), contributing factors (the how?) and root causes (the why?). This allows one comprehensive action plan to be developed and monitored. If used effectively, this process moves the focus from repeated investigation to learning and improvement.

To truly understand the cause of an incident and work out what actions to take you need to understand the role of Human Factors.

Human Factors can be defined as:

"Enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture and organisation on human behaviour and abilities and application of that knowledge in clinical settings" (Catchpole (2010))

There is an emerging consensus that advancing the understanding of Human Factors across the healthcare workforce may have a large impact on reducing harm. Training in Human Factors has been shown to improve safety in various industries but we are still learning about how to adopt and implement this within the NHS.


What are we doing about it?

The improvement academy is developing Human Factors online training. This training will be free to access and will give all staff a grounding in Human Factors theory. More in-depth face-to-face training will be available in 2017.

The Contributory Factors Framework is the first evidence based framework of accident causation in hospitals aimed at optimizing learning and addressing causes of patient safety incidents.


Yorkshire Contributory Factors Framework

Find out more about contributory factor analysis as part of incident investigation using our Yorkshire Contributory Framework resource here.

Other useful resources to support best practice in human factors education:

Clinical Human Factors group

WHO multi curricular guide 


Mel Johnson - Patient Safety Collaborative Programme Manager


01274 383931