Patient safety incident investigations (PSII) are system-based responses to a patient safety incident for learning and improvement. Typically, a PSII includes four phases: planning, information gathering, synthesis, and interpreting and improving.

More meaningful involvement can help reduce the risk of compounded harm for patients, families and staff, and can improve organisational learning, by listening to and valuing different perspectives.

The Learn Together project engaged with, and learnt from, the experiences of everyone involved in investigations – patients, families, staff, investigators, policy makers, and other key stakeholders – to find out their needs during, and experiences of, the investigation process.

Together, we co-designed new guidance to make investigations more human and meaningful for those involved, and support better organisational learning.

As described in the Patient Safety Incident Response Framework (PSIRF) engagement principles, those affected by a patient safety incident must have clear information about the purpose of any learning response, and what to expect from the process. Organisations will need to provide this information to those affected.

When organisations need to undertake a Patient Safety Incident Investigation, our co-designed guidance can be downloaded and used to provide this information for patients, service users and their families.

Alongside this information, you can also download specific guidance for investigators to guide engagement and involvement activity, as well as a guidance booklet aimed at supporting any healthcare staff involved in the investigation.