We investigate patient safety concerns across England to improve NHS care at a national level.
We examine a patient safety event involving an 87-year-old man on anticoagulation medication and outline learning prompts for NHS trusts. The report demonstrates the highly complex nature of clinical decision-making, and why a ‘systems’ view is necessary to improve medication safety.
There are no overarching principles that all health and care providers and integrated care boards can use which enable a consistent approach to safety management. This creates a difference in understanding between organisations, including accountability for patient safety within organisations.
Significant systemic issues, lack of patient and family involvement, and cultures of fear and blame contribute to mental health services not learning from inpatient deaths.
We aim to be the global leader in professional, high quality healthcare safety investigations. We investigate patient safety concerns across England to improve NHS care at a national level. Our investigations do not find blame or liability with individuals or organisations. Information shared with us is confidential and protected by law.
We are a fully independent arm’s length body of the Department of Health and Social Care.
We can investigate patient safety concerns that occur in England during the provision of healthcare services, and that have or may have implications for the safety of patients.
Our investigations can consider healthcare provided in the NHS and the independent sector. Where an investigation relates to an incident that did not occur in the NHS, we must consider whether NHS systems and practices could be improved because of our investigation.
We can also be directed to investigate a patient safety concern by the Secretary of State for Health and Social Care.
Our CPD accredited education programme is delivered by healthcare safety investigation experts.
We offer a range of courses to support development and help embed professional safety investigations across the NHS. For NHS staff in England, courses run online and are free of charge to attend. Courses are also available to fee paying learners outside of the NHS in England.
Our flagship course – A systems approach to investigating and learning from patient safety incidents – launches new cohorts throughout the year.
We would like to hear from everyone, including patients, families and NHS and healthcare staff.
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