New blueprint for healthcare investigators could save lives

A first-of-its-kind framework has mapped the exact skills and qualities healthcare safety investigators need to prevent repeated harm to patients, offering a way forward from the old-style blame and retrain approach that has dominated incident investigations for decades.

Published this week in Safety Science, the framework identifies 38 competencies that separate effective investigators from those who simply go through the motions. The research reveals a fundamental shift in what investigators need:

Globally, almost three million people die each year due to unsafe healthcare. In England alone, the economic cost of unsafe care is estimated at £14.7 billion annually. Without skilled investigators capable of uncovering the range of factors that contribute to unsafe healthcare, the same incidents will continue to repeat and patients will remain at risk.

Dr Rosemary Lim, lead author of the study at the University of Reading, said: The 'blame and retrain' approach for frontline workers involved in healthcare incidents is old news. Yet investigations have continued to focus on individual fault because, until now, there has been no agreed set of competencies anywhere in the world defining what skilled investigators should actually do instead.

"Inconsistent investigations often miss the scope of contributory factors when healthcare goes wrong such as impossible workloads, poorly designed systems, or incompatible technology, and instead default to blaming individuals or recommending superficial fixes like retraining staff.

"Our study makes clear that investigators need more than technical expertise to ensure patient safety. The right combination of skills, knowledge and personal qualities is essential if we are to prevent the same harm happening to patients, families and staff again and again."

The research involved 28 experts, including practising investigators, educators and policymakers, who took part in a rigorous two-round consultation process to reach consensus on what defines competent investigation practice. The University of Reading co-led the research with the Health Services Safety Investigations Body (HSSIB).