Dr Stephen Drage on HSIB & improving patient safety

In this blog, Dr. Stephen Drage, Director of Investigations for the Healthcare Safety Investigation Branch (@hsib_org), gives a detailed insight into HSIB, the importance of improving patient safety and the two types of investigations identifying contributing factors that have led to harm or have the potential to harm patients.

Hey Inspector Clouseau! Where’s the Deer Stalker, Sherlock?

This is just some of the ’friendly’ banter I receive from ICM colleagues when I introduce my new job as Director of Investigations for the Healthcare Safety Investigation Branch (HSIB). The reality is less entertaining but hugely important: to improve patient safety through effective and independent investigations that do not apportion blame or liability. 

I took up my role as a Director of HSIB to continue my interest in patient safety, human factors and leadership for quality improvement. In my career in ICM, and more recently as a Deputy Medical Director in Sussex, I have spent time with many patients, families and staff who have suffered harm as a result of adverse events in healthcare. 

From the investigations I have led, such events arise as a result of the complex interactions between systems, processes and people. So it is unsurprising that the widespread and invidious focus on individual failure as a solution to medical error has not delivered the required improvements.

HSIB is different.


Who are the Healthcare Safety Investigation Branch (HSIB)?

 Since 2017 HSIB has conducted independent investigations of patient safety concerns in NHS-funded care across England. In some ways this is an attempt to learn from the success of accident investigation in the aviation, rail and marine industries but we understand that healthcare is much more complex than transport.

By the application of safety science and a variety of analysis tools our investigations identify the contributory factors that have led to harm or have the potential to harm patients. The recommendations we make aim to improve healthcare systems and processes to reduce risk and improve safety. We work closely with patients, families and healthcare staff affected by patient safety incidents, and we never attribute blame or liability to individuals.

Our team of investigators and analysts have diverse experience working in healthcare and other safety critical industries and are trained in human factors and safety science. We consult widely to ensure that our work is informed by appropriate clinical and other relevant expertise by the use of Subject Matter Advisers. 

The programmes of investigation

National investigations

These complex and wide-ranging investigations focus on safety risks that are common throughout the NHS. We identify the need to investigate potential incidents or issues based on many sources of information including that provided by healthcare organisations, the public and our own research and analysis of NHS patient safety systems. You can tell us about a safety risk or incident that concerns you by emailing enquiries@hsib.org.uk.

We decide what to investigate based on the scale of risk and harm, the impact on individuals involved and on public confidence in the healthcare system, as well as the potential for learning to prevent future harm. We welcome information about patient safety concerns from the public, but we cannot investigate on behalf of families, staff, organisations or regulators.

Our approach is to identify a ‘reference event’, this is a patient safety incident that has been referred to us or that we have identified from incident databases that exemplifies the safety risk of concern. Although we carry out a thorough investigation of the reference event it does not replace the local ‘SI’ investigation as our inquiry is designed to identify and confirm the nationally significant safety risks. The investigation then moves on to explore the safety risks and issues identified at a national level (i.e. policy, guidance and organisation of services etc).

Our investigations are all available on our website www.hsib.org.uk. National investigations of particular interest to ICS members may be Failure to act on unexpected radiological findings, Recognising and Responding to Critically Unwell Patients, Transport of critically ill patients and Wrong Route Medication.

Maternity investigations

From 1 April 2018, we became responsible for all patient safety investigations of maternity incidents occurring in the NHS which meet criteria for the Each Baby Counts programme. The purpose of these investigations is to identify learning and improvement in maternity services, and common themes that offer opportunity for system-wide change.

For these incidents HSIB’s investigation replaces the local SI investigation, although the trust remains responsible for Duty of Candour. We work closely with parents and families, healthcare staff and organisations during an investigation. Our reports are provided directly to the families involved and to the trust. The trust is responsible for actioning any safety recommendations we make as a result of these investigations.

We are now operating in all trusts across England, have trained 150 investigators and have commenced over 600 investigations in 18 months of operation. An amazing achievement in its own right. The volume of data is helping to identify themes to improve the provision of maternity services.

Have your say

I’m excited by the work of HSIB and the possibility to influence positive change in the NHS. We bring a new approach to safety investigation in healthcare. We value feedback on our reports and our investigations so please contact me via enquiries@hsib.org.uk with feedback, questions or safety concerns.