How Were Patient Safety Incidents Responded to, Investigated, and Learned From Within the English National Health Service Before the Implementation of the Patient Safety Incident Response Framework? A Rapid Review

Objective: To understand how National Health Service organizations routinely responded to, investigated, and learned from patient safety incidents in England before the implementation of the Patient Safety Incident Response Framework, and to identify associated success criteria and barriers.

Methods: We followed rapid review methodology and searched 2 electronic databases. We aimed to identify and synthesize literature regarding patient safety incident response, investigation, and learning within the English National Health Service, before the implementation of the Patient Safety Incident Response Framework.

Results: Nineteen articles were included. A narrative synthesis generated 4 concepts: (1) a multifaceted reporting culture, (2) investigation processes, (3) the landscape of support and involvement, and (4) opportunities to learn. Barriers to incident reporting included time, task characteristics, a culture of blame, and lack of feedback. Root cause analysis was cited as the most common investigation method. Studies outlined points of support and involvement for patients and families, the importance of supporting and involving patients and families, and acknowledged contributions from patients and families may be overlooked currently. For health care staff, the need for timely and personalized support soon after an incident was emphasized. Studies underlined the limitations of current approaches to learning and improvement.

Conclusions: These findings lend support to the challenges associated with health care systems’ infrastructures and strategies for responding to and learning from patient safety incidents. These challenges centre on 2 interrelated issues: the investigative challenges of rigorously conducting systems analysis and learning-oriented improvement; and the relational challenges of supporting genuine relationships of care, open and honest communication, and supportive engagement after patient safety incidents.