Improving NHS investigation of patient safety incidents
- Peter McCulloch,
- Helen Higham,
- Lauren Morgan,
- Dawn Benson
Abstract
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