New insights from research into patient safety investigations By Lorelle Bowditch and colleagues (BMJ Quality & Safety, 2025) Health systems across the world are committed to learning from patient safety incidents. But do our investigations truly reflect systems thinking —or do they still focus on individual errors? A new Australian study by Bowditch et al., published in BMJ Quality & Safety , explores this question by examining 300 patient safety investigations  from 56 heal

This report shares learning and insights from HSSIB’s education and investigation teams about patient safety incident investigation under the Patient Safety Incident Response Framework (PSIRF). What they found: System-based approach welcomed  but skills gap persists : staff know the toolkit, yet need more hands-on support—especially in mental health investigations. Engagement is valued but variable : time pressure limits interviews and compassionate conversations; specialist

“Perceptions and Experiences of Consumer Representatives on Patient Safety Investigation Teams: A Qualitative Analysis” by Peter D. Hibbert et al. (2025)"  The study explores how consumer representatives (CRs) — individuals with lived-experience of safety incidents or patient care — perceive and experience their role when invited to join patient-safety investigation teams. It asks: What benefits do CRs bring? What are the challenges? And how do CRs feel about being part of th

Patient safety has long been fram ed as a technical challenge: standardize protocols, reduce errors, and audit relentlessly. But the...

Martha’s Rule was born from the tragic loss of 13-year-old Martha Mills, whose parents’ concerns about her deterioration went unheard....

is a powerful tool for advancing safety by systematically exploring why things go right. Unlike traditional approaches that focus solely...

The Launch of the Patient Safety (Notifiable Incidents and Open Disclosure) Act 2023 in Ireland In a significant step forward for...

A recent article in the Harvard Business Review by Kedar S. Mate, Josh Clark, and Jess Salvon-Harman emphasizes a pivotal shift in...

On 9th March 2023, the NHS published the results of their 2022 staff survey . Over 636,348 staff from 246 organisations took part, it...

In the aftermath of COVID-19 government health leaders from around the globe attended a Summit in Montreux, Switzerland. The Montreaux...

Patricia McGaffigan's article ' Avoiding "drift" into harm. Healthcare Executive. 2022 Sept;38(5):46-49; recognises the danger of...

I recently stumbled on an excellent series of resources in the form of Podcasts from THIS.Institute (https://www.thisinstitute.cam.ac.uk/...

A recent article in Becker's Hospital Review outlined 3 factors that contribute to repeat medical errors, care complications or lost...

The launch of the Patient Safety Incident Framework (PSIF) by NHS England represents a major change in the way NHS organisations will...

The tragic death of Mr Charlene Murphey, which resulted in the conviction of Nurse RaDonda Vaught, has sent shockwaves through the health...

Anne Brennan Gavin Lavery

CLS Educate programmes have a strong focus on group working on real-life case scenarios and recognise the importance of our programme...

Commencing in 2022 we will deliver their accredited CLS Building Competency programme virtually to Trusts in Northern Ireland. The...