This thought paper explores how healthcare systems can develop a system-wide approach to investigating and learning from the most serious patient safety issues, and examines the organisational infrastructure that is needed to support this.

Many safety-critical industries depend on the work of an independent, national safety investigator to investigate the most serious risks that span the system and to develop safety recommendations that target any and all organisations that need to work together to address those risks–from front-line providers to regulators.

The creation of the Healthcare Safety Investigation Branch will pioneer this approach in England. This paper defines the fundamental principles, the practical challenges and the considerable opportunities that any healthcare system must grapple with in the development of a system-wide safety investigator—and in building an infrastructure that supports investigating for improvement.

To download the thought paper please click here