Investigating Patient Safety Incidents

Investigating Patient Safety Incidents; collecting and collating data to facilitate effective Root Cause Analysis

The National Patient Safety Agency (NPSA) is promoting Root Cause Analysis (RCA) as a means of gaining organisational and national learning following a patient safety incident. To undertake robust root cause analysis comprehensive data is needed from a rigorous and searching investigation of an incident. Without such thoroughness it is not possible to extract lessons that will impact upon practice. A major failing in the investigation process is the lack of training provided for staff required to gather data following an incident.

Recent national reports find most incident investigation systems used by healthcare organisations are:

Unidisciplinary
Subjective
Inconsistent
Failing to inform the analysis process
Focussed upon human failings rather than system failures
Not facilitating changes in practice

This programme provides an overview of the methods and techniques used for investigating patient safety incidents. Participants will be made aware of the importance of ensuring investigation data is relevant, reliable and complies with legal requirements, particularly vital for incidents that ultimately lead to litigation or compensation claims.

Inadequate investigation of a patient safety incident will lead to a failure in identifying the true causal factors and so preclude opportunities for learning lessons and changing practice

The course is interactive and draws on the participants knowledge, skills and experience, using case studies and simulation. It develops skills in a range of investigation techniques.

Course Objectives
The course objective is to deliver a programme which can impart practical skills and techniques in one day. Participants will be equipped with the knowledge, skills and confidence to undertake deep, probing, robust and legally sound investigations into patient safety incidents.

Course participants will learn to:

Classify incidents and determine the level of investigation required
Appoint appropriate investigator(s)
Gather data - (people, documentation, site etc)
Ensure data/evidence meets legal requirements
Undertake multidisciplinary reviews
Identify causal factors and map information using appropriate methodology
Select relevant root cause analysis tools
Devise action plans and select relevant audit tools to monitor change

Investigation Courses

Global Air Training provides Incident Investigation training courses and programmes tailored to the specific requirements of the client organisation.