Louch Gemma, Macrae Carl, Talbot Rebecca, McHugh Siobhan, O'Hara Jane K
School of Healthcare, University of Leeds, Leeds.
Business School, University of Nottingham, Nottingham.
J Patient Saf. 2025 Aug 1;21(5):e42-e55. doi: 10.1097/PTS.0000000000001349. Epub 2025 May 9.
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.
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.
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.
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.
了解在《患者安全事件应对框架》实施之前，英国国民医疗服务体系组织如何对患者安全事件进行常规应对、调查并从中吸取教训，以及确定相关的成功标准和障碍。
我们遵循快速综述方法，检索了2个电子数据库。我们旨在识别和综合有关在《患者安全事件应对框架》实施之前，英国国民医疗服务体系内患者安全事件应对、调查和学习的文献。
纳入了19篇文章。叙述性综述产生了4个概念：（1）多方面的报告文化，（2）调查过程，（3）支持与参与的情况，（4）学习机会。事件报告的障碍包括时间、任务特点、责备文化和缺乏反馈。根本原因分析被认为是最常用的调查方法。研究概述了患者和家属的支持与参与点、支持和让患者及家属参与的重要性，并承认目前患者和家属的贡献可能被忽视。对于医护人员，强调了事件发生后及时提供个性化支持的必要性。研究强调了当前学习和改进方法的局限性。
这些发现支持了与医疗保健系统基础设施以及应对患者安全事件并从中吸取教训的策略相关的挑战。这些挑战集中在两个相互关联的问题上：严格进行系统分析和以学习为导向的改进所面临的调查挑战；以及在患者安全事件发生后，支持真正的关怀关系、开放和诚实的沟通以及支持性参与所面临的关系挑战。
