How HSSIB contributes to patient safety: a view from Sweden

In the Swedish healthcare system, it is estimated that approximately 2,000 patients yearly sustain injuries that lead to a fatal outcome. Globally, as many as 3 million deaths occur annually due to unsafe care. There is no system, such as road, rail, marine, aviation or other sectors, where the potential for safety learnings is so prominent. A safe and effective healthcare system is paramount for alleviating personal suffering, but also for the significant loss to society.

Swedish Accident Investigation Authority

The Swedish Accident Investigation Authority (SHK) is a multi-modal authority charged with the task of performing independent accident investigations for all types of accidents. The main efforts are carried out within the transport sectors, but investigations are also carried out for non-transport accidents.

Non-transport accidents, to which the SHK refers as “other accidents”, can for example be a healthcare incident or accident. The most recent investigation report of a healthcare accident was published by the SHK in 2023. Unfortunately, the SHK has due to a lack of resources not been able to regularly initiate investigations into events within the healthcare sector.

The healthcare sector is a vast and complex system, which allows accident investigators to use all of their know-how, experience and available methods to ascertain what has gone wrong and why. The unique perspective of applying a no-blame systemic methodology serves our community with learning, rather than putting blame on individuals for making mistakes. The added value of an independent no-blame accident investigation is amongst other things the true understanding of highly complex events, where systemic or organisational constraints or issues in the interface between different health services providers can be thoroughly investigated.

Best efforts for safety learning

The HSSIB is, in the eyes of fellow investigative bodies, seen as a good example of the very best efforts for safety learning. The fact that an independent Health Services Safety Investigations Body exists and continuously is investigating accidents and events within the healthcare system and doing so in a methodical fashion serves as an inspiration and something to strive for.

The investigative process follows internationally recognised standards for accident investigation, which is mirrored in the well-established branches of aviation, rail and marine accident investigation.

A marathon, not a sprint

Accident prevention is complex. Dissemination of safety learnings is a process and is probably best seen in the light of the analogy of a marathon versus a sprint. The potential of safety learnings from independent no-blame accident investigations cannot be over-estimated. Publicly available reports, safety learnings and issued recommendations, serve not only the immediate involved parties but can also aid other health service providers in making improvements and developing the quality of care that is given.

Recommendations put forth by an investigative body can have both positive and quantifiable effects in the short-term, but more often than not change takes time. Improving safety is a process and how safety learnings translate to safety improvements or improvement in safety culture can be difficult to quantify, but this does not change the need and value for independent accident investigations.