Preprints are manuscripts made publicly available before they have been submitted for formal peer review and publication. They might contain new research findings or data. Preprints can be a draft or final version of an author's research but must not have been accepted for publication at the time of submission.
posted on 04.01.2019by Peter McCulloch, Helen Higham, Lauren Morgan, Dawn Benson
We discuss the deficiencies of current NHS patient safety investigation and specifically the need for independence and Human Factors training. We describe the theory behind a regional network approach to improving the quality of investigations, and the development of a pilot study. We report outcomes from the first three investigations and the learning gained from the experience of conducting the pilot study. We make recommendations for how this type of solution to the problem of adequate investigation could be further developed