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National learning report : a thematic analysis of HSIB’s first 22 national investigations

The adoption of a safety management system could facilitate an operational shift within healthcare.

HSIB (Healthcare Safety Investigation Branch), which conduct independent investigations relating to patient safety in NHS-funded care, have undertaken a thematic analysis of their first 22 national investigations.

The aim of the report is to:

  • Highlight recurring patient safety themes, as HSIB recognised that similar issues were arising in investigations undertaken in very different clinical fields. The report does not expressly say this, but I anticipate therefore that the issues identified will be applicable across different clinical settings.
  • Demonstrate a qualitative analysis of HSIB’s national investigations in a way that is of interest.
  • Open up an inquiry about the role of safety management systems, the principles underpinning them and whether they can be applied to healthcare in the future. This is an important issue and is expanded on a little further below.

A summary is set out below including:

  • The three recurring patient safety themes that were identified, which HSIB consider to represent the most significant threats to patient safety based on the investigations they have undertaken to date, which are likely to be familiar themes to you.
  • The six categories that were chosen, as they represent the fundamental safety management activities used across safety-critical industries (e.g. the aviation industry). You will see that the format of the report focuses on the three above themes and provides examples of the safety recommendations made, utilising each of the six categories detailed below.
  • Safety management systems, which are an organised approach to managing safety.

The three recurring patient safety themes identified are

Recurring patient safety themes

Brief explanation/ issue

Access to care and transitions of care

When patients move between care providers or settings e.g. transfer of unwell patients between hospitals, timely access to mental health service, falling to communicate unexpected significant radiological findings. The barriers can be physical, financial, organisational, social or cultural.

Communication and decision making.

The delivery of healthcare depends on timely communication and effective decision-making, which can be impacted upon by pressures on the health system, e.g. risks become apparent when a serious health condition is not detected or failing to escalate/ refer to a specialist team to meet the patient’s needs. HSIB found that communication and decision-making are dependent on each other.

Checking at the point of care

Routine activities require healthcare workers to check that the intended treatment is being delivered correctly, at the point of care when health workers and medical devices come in to direct contact with patients. There is a risk that the healthcare worker may select the wrong treatment or forget a required step. The burden is often on the healthcare worker to avoid/mitigate these errors. Instead, the aim should be to develop systems and procedures designed to mitigate known risks. This is a fundamental principle of human factors and ergonomics. Some opportunities for error can be mitigated by better design and the focus should be on improved systems rather than a healthcare worker being ‘more vigilant’, which HSIB found to be an ineffective safety recommendation, e.g. medication errors, such as inadvertently giving oral drugs intravenously, using equipment that is not fit for purpose.

The analysis also looked at 85 safety recommendations made in the 22 investigations, which were grouped into one or more of six categories. As referred to above, the categories were chosen as they represent the fundamental safety management activities used across safety-critical industries (such as the aviation industry). The report focuses on the three above themes and provides examples of the safety recommendations made utilising each of the six categories below

The six categories are


Brief explanation/ issue

Identification of patient hazards

Something that has the potential to contribute to a patient safety outcome e.g. not being able to see the product label on a bag of IV fluid connected to a patient.

Improving the management of known patient risks

Known safety risks have the potential to result in undesirable outcomes even when there are proposed ways of managing the risk.

Monitoring of patient safety performance

Such as monitoring the interface between care providers that a patient may experience along the patient journey.

Evaluation of patient safety interventions

For example, technology should be easy for healthcare staff to use and ease pressure rather than add additional unnecessary workload.

Training and education for patient safety

Effective education and training are required, such as when new procedures are developed which are tested/evaluated.

Promotion of patient safety

Safety is an important aspect of patient care, such as where a patient can have the relevant information to be able to look out for specific symptoms and respond accordingly. They also need to be provided with multiple ways of communicating and accessing information.

Safety management systems

The report acknowledges that the identified safety management activities needed to address the safety recommendations reflect components of existing patient safety approaches in the NHS Patient Safety Strategy. Significantly, they are also the constituent parts of safety management systems. A safety management system is an organised approach to managing safety. It sets out the necessary system-wide processes needed to identify new safety hazards and effectively manage known safety risks. It also monitors safety performance, manages change, and promotes effective safety communication.

What would a safety management system for healthcare look like?

The report says: Healthcare has a complex landscape of stakeholders. Those with regulatory power or influence are often independently responsible for various safety activities. However, these activities are not always integrated across the system to allow for a unified, proactive approach. The adoption of a safety management system could facilitate an operational shift within healthcare. This necessitates that the system provides proof that the system is safe now, and that it will be safe in the future. This represents a shift from proving that something can be dangerous, to proving that things are safe (Leary, 2021).

Safety governance systems and patient safety roles form a basic structure common to many NHS organisations with a focus on quality improvement. However, current patient safety roles do not ensure that the individuals employed have expertise in safety management, an essential requirement within other safety-critical industries. Vincent et al (2013) report into how safety is managed in healthcare has highlighted that although healthcare has processes for quality improvement, it has not developed an embedded safety management system. The healthcare system needs to be both reactive to safety concerns and proactive to achieve longer-term safety objectives.


It is important to point out that the report does not look at the impact of the various recommendations on improving patient safety or assess how well they have been acted upon, as HSIB is not a regulator and therefore it is not their role. The onus is on the addressee (e.g. NHSE) to decide how best to meet a recommendation. That said, the report does recognise that there is a gap in monitoring the impact of recommendations, as some recommendations may have had a beneficial impact whilst others have not, so it seems there is no clear way of knowing at present, and HSIB anticipate that there will be provision in the future to address this, so watch this space.

A key message from the report and HSIB is that a healthcare system needs to be both reactive to safety concerns and proactive to achieve longer-term safety objectives. Therefore, it is clear that patient safety across the health service has made significant progress but equally needs to continue on a journey to embrace new and alternative approaches and develop expertise to embed patient safety long term.  

The full HSIB report.

If there is anything you want to discuss or if you require any further assistance relating to the issues raised, please liaise with Alison Brennan or any of our healthcare solicitors

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