Dr Kathryn Leask
A new patient safety body is examining where the English healthcare system can be improved, to prevent patient safety incidents.
Some healthcare professionals may not have come across the Healthcare Safety Investigation Branch (HSIB) yet, as it is a relatively new organisation, but the MDU has already advised a number of doctors who have been asked to take part in its investigations.
HSIB began work in April 2017, carrying out independent investigations to improve patient safety without apportioning blame or liability. It is not a regulator, nor is it responsible for assessing professional practice. Following an investigation, the HSIB makes safety recommendations aimed at improving systems and processes for patient safety, with the aim of sharing what they have learnt across the healthcare system. The organisation is funded by the Department of Health and Social Care, but operates independently from it and the CQC.
For a more in-depth introduction to the organisation, you can read an interview with its chief investigator in a recent issue of the journal.
Types of investigations
The HSIB will investigate up to 30 cases each year based on analysis of a wide range of source material including NHS patient safety reporting, as well as information provided to HSIB by healthcare staff, organisations and the public. The decision to investigate is made based on detailed criteria and takes into account the impact, the systemic risk and the learning potential the case raises. In 2018 it also became responsible for conducting all maternity safety investigations in the NHS which meet criteria under the RCOG's Each Baby Counts programme, with the aim of achieving rapid learning across maternity services.
HSIB aims its recommendations at national organisations with the power to deliver change in systems and processes to improve patient safety. However, doctors working in services covered in an HSIB investigation may find the reports help with understanding the ways that system, organisational and human factors can impact on safe professional practice.
Portable oxygen systems
As a result of problems experienced during a resuscitation attempt where it was found that the reservoir bag attached to an oxygen cylinder was not inflating between breaths, a trust asked the HSIB to examine portable oxygen systems.
As a result of the investigation a number of safety observations and recommendations were made, including around the design of portable oxygen systems and how they are regulated by the Medicines and Healthcare products Regulatory Authority (MHRA).
An ongoing investigation into the diagnosis and management of acute onset testicular pain came about after a mother raised potential safety issues following the treatment of her son, who had an orchidectomy due to a testicular torsion. The full investigation aims to develop a greater understanding of variations in diagnosing and treating the condition as well as the impact on patients and clinicians.
Other ongoing investigations include dealing with critically ill patients, the management of chronic health conditions in prisons and the diagnosis and management of ectopic pregnancy.
The results of completed investigations have already been seen. For example, an investigation into administering a wrong site nerve block identified variations in practice and recommended compliance with national and local guidance. The HSIB also asked the Royal College of Anaesthetists to establish a specialist working group to evaluate current practices and consider how safety initiatives can be standardised in training and practice for anaesthetists.
An investigation into the provision of mental health care to patients presenting at the emergency department made a number of recommendations, including using national guidelines for patients seen following a mental health emergency. Another was that during their inspections, the Care Quality Commission gives equal weight to the quality of care provided to people with urgent mental health problems, as well as physical health.
Taking part in a HSIB investigation
As it becomes more established, it's more likely that doctors involved in a clinical incident may be asked to participate in an HSIB investigation. The organisation has access to local investigation reports and can interview staff or any other relevant person including patients. HSIB also liaises with independent advisers from across the healthcare system to ensure appropriate clinical expertise in its work.
Bear in mind that the emphasis of an investigation is to learn from the event and share any lessons across the healthcare system, rather than apportion blame. It is anticipated that legislation will be put in place that means that evidence gathered in its national investigations is under protected disclosure, often called 'safe space', which protects individuals' interviews from being disclosed without High Court order.
Our organisation is learning, from each investigation, how to develop high-quality safety investigations in this context. Support and engagement from doctors are essential.
Speaking to the MDU, HSIB's chief investigator Keith Conradi said that, 'establishing a new, independent organisation to explore patient safety concerns across the NHS is a challenge. While there is much the NHS can gain from approaches in other safety-critical industries such as aviation, where I've come from, there are unique complexities to healthcare.
'This means that our organisation is learning, from each investigation, how to develop high-quality safety investigations in this context. Support and engagement from doctors are essential.
'Our investigators find that doctors value our perspective and approach. By understanding the ways that systems, processes and working environments influence clinical practice, we have a real opportunity to transform patient safety. Our success depends on collaboration with doctors and their colleagues across the healthcare system.'
The MDU is on hand to support doctors called upon to provide information to the HSIB.
Dr Kathryn Leask
BSc (Hons) MBChB (Hons) LLB MA MRCPCH FFFLM MRCPathME DMedEth
Kathryn has been a medico-legal adviser with the MDU since 2007 and is a team leader, trainer and mentor in the medical advisory department. Before joining the MDU, she worked in paediatrics gaining her MRCPCH in 2002 and did her specialty training in clinical genetics. She has an MA in Health Care Ethics and Law, a Bachelor of Law and a Professional Doctorate in Medical Ethics. She is also a fellow of the Faculty of Forensic and Legal Medicine and has previously been an examiner and deputy chief examiner for the faculty. Kathryn is currently a member of the faculty’s training and education subcommittee and a member of the Royal College of Pathologists (medical examiner).
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