Exploring Serious Incident Investigation Practices in the NHS: towards a patient safety culture in Community Healthcare NHS Trusts

Patient safety is a major challenge in healthcare systems worldwide. In an attempt to make healthcare safer, practices have been adopted from other safety critical industries, accepting the underlying theory of high reliability organisations (HROs). The UK's NHS has heavily invested in the use of root cause analysis (RCA), a set of methods for investigating serious incidents (Sis) to learn and make improvements. Research and experience, translated into guidance to practice, specifies a necessary set of investigation disciplines and assurance processes to achieve thorough and credible investigations and to sustain a patient safety culture. This study examines RCA practice within two Community Healthcare NHS Trusts. It identifies factors that shape the investigation process and asks whether the conditions understood to support investigation and learning are present. Across the two organisations, an audit of three completed RCA reports and associated documents was supplemented by observation of 21 RCA investigation cases at three RCA meetings, and 13 semi-structured interviews with RCA teams, including senior leaders that regulate patient safety or have regional system oversight. Data were analysed against themes drawn from literature on patient safety culture and RCA practice and the National Patient Safety Agency's 'gold' standard RCA practices for investigating Sis. This study findings were consistent with other, recent studies of RCA practice in acute care settings in the United Kingdom and other developed countries. In sum, theory and policy had been 'lost in translation'. Investigations lacked the necessary disciplines for conducting thorough and credible RCAs and opportunities for learning from them were correspondingly limited. Governance and oversight systems were also inadequate and failed to challenge or support investigations. Despite sustained attempts to encourage a positive patient safety culture within the NHS, this study suggests patient safety culture remains weak. Sixteen specific recommendations are offered in response to detailed findings