How can specialist investigation agencies inform system-wide learning for patient safety? A qualitative study of perspectives on the early years of the English healthcare safety investigation branch

Crompton, Amanda; Waring, Justin; Macrae, Carl; Overton, Charlotte; Benneyworth, Rosie

Abstract

Objectives
System-wide learning for patient safety is a core challenge for the health care sector, despite the prevalence of localised reporting and learning approaches. There is growing interest in how health care services could emulate other safety-critical sectors with the introduction of specialist safety investigation agencies to inform sector-wide safety. This paper reports on a study of the introduction and early operation of one such agency in the English health and care system.
Methods
This was a qualitative interview study carried out between 2019 and 2021 and co-designed through a partnership between University researchers and the Executive Team from the Healthcare Safety Investigation Branch (HSIB) to explore the organisational development of this ‘first of type’ organisation. The study involved interviews with 33 internal and external stakeholders and documentary analysis of HSIB reports.
Results
The study findings highlight the organisational competencies and developmental challenges experienced in the early years of HSIB operations focusing on (i) independence and fit within the wider system; (ii) the selection and scope of investigations; (iii) the methodology and investigation approach; and (iv) the skill and competencies of investigators.
Conclusions
This study offers practical learning to health care decision-makers about the importance of securing independence and integration, about the production of system-wide learning, the standardisation of robust methodologies and the support for a multidisciplinary specialist workforce.

Citation

Crompton, A., Waring, J., Macrae, C., Overton, C., & Benneyworth, R. (2025). How can specialist investigation agencies inform system-wide learning for patient safety? A qualitative study of perspectives on the early years of the English healthcare safety investigation branch. Journal of Health Services Research and Policy, 30(1), 31-39. https://doi.org/10.1177/13558196241291816

• Journal Article Type: Article
• Acceptance Date: Sep 25, 2024
• Online Publication Date: Nov 5, 2024
• Publication Date: 2025-01
• Deposit Date: Nov 21, 2024
• Publicly Available Date: Nov 21, 2024
• Journal: Journal of Health Services Research and Policy
• Print ISSN: 1355-8196
• Electronic ISSN: 1758-1060
• Publisher: SAGE Publications
• Peer Reviewed: Peer Reviewed
• Volume: 30
• Issue: 1
• Pages: 31-39
• DOI: https://doi.org/10.1177/13558196241291816
• Keywords: investigation, patient safety, learning, safety investigation, discipline: social science, qualitative methods, evaluation
• Public URL: https://nottingham-repository.worktribe.com/output/41823559
• Publisher URL: https://journals.sagepub.com/doi/10.1177/13558196241291816