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Investigating Patient Safety - Evidence Based Framework

Patient safety incidents (PSIs) are common and can lead to fatal outcomes. Effective investigation of PSIs is essential to optimize learning and take action to prevent further incidents occurring. Good practice in incidents investigation has been described by the NPSA in the London Protocol. A key step in this protocol is the identification of all contributory factors (See Step F in Figure below). The Clinical Human Factors Group also recommends effective contributory factor analysis as part of serious incident investigation (see link in "Further Information" section).

In 2012, a systematic review of 83 research studies focusing on the causes of hospital patient safety incidents was conducted. The result of this piece of work is the first evidence based framework of accident causation in hospitals: the Yorkshire Contributory Factors Framework.

The Yorkshire Contributory Factors Framework is a tool which has an evidence base for optimizing learning and addressing causes of patient safety incidents by helping clinicians, risk managers and patient safety officers identify contributory factors of PSIs. Incidents that occur in a hospital setting have been well studied and all contributory factors have been mapped. Please refer to the BMJ document in the "Further Information" section above.

Based on this research, a team of practicing clinicians with human factors experts has adapted the evidence to a pragmatic 2 page framework. The YCFF includes all sixteen domains of the evidence-based domains. Through an iterative process with input from risk managers, clinicians and human factors experts, the document has been improved. Feel free to download and adapt the latest version by clicking on the image below:

The document suggests questions that you might want to ask of those involved in the incident. The underlying aim of this tool is not to ignore individual accountability for unsafe care, but to try to develop a more sophisticated understanding of the factors that cause incidents. These factors can then be addressed through changes in systems, structures and local working conditions. Finding the true causes of patient safety incidents offers an opportunity to address systemic flaws effectively, for the benefit of all our future patients.

Patient Voice

The AHSN Improvement Academy is using an innovative method of capturing the 'voice of patients' in improving the safety of their healthcare. Read about the PRASE (Patient Reporting and Action for a Safe Environment) tool here.