Patient safety investigations are ultimately about ensuring we learn from mistakes, and take meaningful action to improve. Here are some of the things I look for in a great patient safety investigation. Have I missed anything? ✅️ A robust Terms of Reference - your guide through the process ✅️ Attention to detail - the small details matter, and can often lead us to the root cause ✅️ Engagement at all levels - from patients and loved ones to staff at all levels, we need to be speaking to everyone who might have useful information ✅️ Asking 'why?' - until we get to the root cause - '5 Whys' is a good guide ✅️ Findings that tell a story - a good narrative helps build the picture ✅️ Robust recommendations that relate to both the ToR and findings Making sure we include the above helps build a SMART action plan that helps us improve
Such an important topic 👏
Dep. Head of Quality, Safety & Assurance at Velindre NHS Trust
8moThank you, Peter Thomas MSc. Patient safety investigations are often an unpopular topic, but any healthcare organisation, large or small, overlooking their importance will ultimately repeat the same mistakes