| Document
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Author Brook Howells |
| Abstract The Patient Safety Incident Response Framework (PSIRF) launched in 2022 aims to improve healthcare safety through improved learning from incidents. Effective investigations are a critical part of safety management and one area that requires further research is in how incident analysis can take a safety-II approach to understand how systems adapt to maintain safety and what enables operational staff to have positive adaptive capacity. This study utilised appreciative inquiry to assess the work as done of investigators, in particular relation to how they identify positive adaptive practices. Qualitative interviews with investigators and safety specialists from safety-critical industries were used to identify current methods and practice, plus perceptions of how safety-II might be enabled in investigations. The main findings were that investigators already identify positive adaptive practices by operational staff, although it is not a priority focus and minimally reported. There was less evidence that current practice facilitates greater understanding of factors that enable positive adaptations. The diversity of investigation methodologies used and the value of multi-disciplinary investigation teams was a common theme. The impact of safety-II on kindness – both within investigations and for wider cultural change – was also a key finding, although there was variation between industries that merits further analysis. This study has implications for how investigative practice and skills are taught and refined, and how safety-II might be integrated within wider safety campaigns. |
