Mesinioti, P. orcid.org/0000-0002-2071-7303, Macrae, C., Sheard, L. orcid.org/0000-0002-9241-8361 et al. (3 more authors) (2025) Closing investigations: The role of national policy in shaping structural, organisational and relational constraints on learning from patient safety incidents. Safety Science, 192. 106999. ISSN: 0925-7535
Abstract
This study aimed to understand the role of a national patient safety policy, the Serious Incident Framework, on local organisational practices of responding to, investigating, and learning from patient safety incidents in the National Health Service (NHS) in England. Qualitative interviews were conducted with healthcare professionals in six NHS organisations and analysed using inductive thematic analysis and taking a constant comparison approach. Systemic challenges linked to the policy’s prescriptive requirements were identified, including its emphasis on metrics such as incident closure and harm levels, which often obscured meaningful learning and systemic improvement. The findings highlight the misalignment between the policy’s key aims and principles and its practical implementation, revealing an ‘industry of investigations’ that risked turning the investigative process into a compliance-oriented ‘tick box exercise’. Furthermore, the overspecification of performance requirements coupled with the underspecification of substantive guidance led to variability in investigative processes, organisational capacity and resources, and investigator training and expertise. The involvement of patients and families affected by safety incidents was found to be inconsistent and often limited, with perceptions of senior managers and frontline staff underlining some tensions in operationalising large patient safety policies. The analysis considers how the development and implementation of national safety incident policies needs to carefully and intelligently balance the need for adaptive flexibility, clarity of guidance, and specification of organisational resourcing and infrastructure to ensure future national policy can effectively support local practices of learning from safety incidents.
Metadata
Item Type: | Article |
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Authors/Creators: |
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Copyright, Publisher and Additional Information: | © 2025 The Authors. This is an open access article under the terms of the Creative Commons Attribution License (CC-BY 4.0), which permits unrestricted use, distribution and reproduction in any medium, provided the original work is properly cited. |
Dates: |
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Institution: | The University of Leeds |
Academic Units: | The University of Leeds > Faculty of Medicine and Health (Leeds) > School of Healthcare (Leeds) |
Funding Information: | Funder Grant number NIHR National Inst Health Research NIHR133742 |
Date Deposited: | 29 Sep 2025 11:01 |
Last Modified: | 29 Sep 2025 11:01 |
Status: | Published |
Publisher: | Elsevier |
Identification Number: | 10.1016/j.ssci.2025.106999 |
Open Archives Initiative ID (OAI ID): | oai:eprints.whiterose.ac.uk:232240 |