Incident investigation remains a cornerstone of patient safety management and improvement, with subsequent recommendations meant to drive action and improvement. In this Yorkshire and Humber ARC PhD, a scoping review identified that there are no specific tools or approaches used to generate recommendations, and they focus on training or adding or improving policies. Recommendations largely focus on staff knowledge and skills, with only 7% considered system-focused, such as standardising equipment, architectural changes, or simplifying processes.
A second study, currently being written, has examined the association between incident outcome-knowledge and judgements and responses by investigators.
A third study, currently being carried out, is a modified Delphi, aiming to identify and establish whether consensus can be achieved on a set of criteria to judge the quality of healthcare incident investigations and recommendations.
