Risk Controls Identified in Action Plans Following Serious Incident Investigations in Secondary Care: A Qualitative...

Area of Science:

• Patient Safety
• Healthcare Quality Improvement
• Risk Management

Background:

• Effective incident investigations are crucial for enhancing patient safety.
• The quality of risk controls recommended in investigation reports significantly impacts their effectiveness.
• Previous studies highlight the need to improve the translation of incident findings into actionable safety measures.

Purpose of the Study:

• To identify the range and strength of risk controls from serious incident investigations.
• To map these controls against identified contributory factors.
• To characterize the nature of proposed risk controls to understand their effectiveness.

Main Methods:

• Content analysis of 126 action plans from serious incident investigation reports.
• Coding risk controls against contributory factors.
• Assessing risk control strength using a hierarchy of controls model.
• Thematic analysis of proposed risk control characteristics.

Main Results:

• 15% of contributory factors were not addressed by any risk controls.
• 74% of 822 proposed risk controls were assessed as weak, often focusing on individual rather than systemic issues.
• Identified approaches included improving performance, standardizing practice, enhancing the environment, communication, process improvements, and disciplinary actions.

Conclusions:

• Significant gaps exist in translating serious incident investigations into systemic patient safety improvements.
• Shortfalls include unaddressed factors and a prevalence of weak, individualized risk controls.
• Improving risk control quality requires human factors expertise, a theory-of-change approach, evaluation, and shared learning.