Exploring Human Factors 4: Learning from patient safety investigations – greater improvement using human factors

This session will outline how patient safety investigations are one of a range of approaches that allow healthcare organisations to learn.

We will consider why organisations struggle to learn, how taking a systems-based approach can support impactful improvement, how restoration for those involved is key to a systems-based approach to learning, and how the English NHS Patient Safety Incident Response Framework (PSIRF) acts as a model for other countries to follow.

This will be delivered through lecture style presentation and case studies.

By the end of the session, you will be able to:

• Recognise the role that patient safety investigation plays in learning, and the barriers to this
• Describe why a systems-based approach is important for learning from patient safety investigations
• Explain the importance of taking a restorative approach to healing after harm

Chair:

• Dr Yogini Jani, Clinical Safety Lead – Digital Healthcare, University College London Hospitals NHS Foundation Trust

Speakers:

• Professor Mark Sujan, Senior Investigation Science Educator, Health Services Safety Investigation Body (HSSIB)
• Dr Clare Crowley, Pharmacist and Senior Safety Investigator, HSSIB