A Norwegian ambulance drives with it's blue lights flashing along a road in Oslo.

Building an international network for patient safety investigation

By Rosie Benneyworth

4 May 2023

Our Chief Investigator, Rosie Benneyworth, writes about exciting developments in the world of international patient safety investigation.

This blog post was published by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

Rosie Benneyworth
Rosie Benneyworth, Chief Investigator.

The emergence of patient safety investigation bodies

HSIB became the world’s first operational national patient safety investigation agency in 2017. Since that time, national patient safety investigation has continued to develop in other countries in recognition of the need for high quality, professional patient safety investigation and insight to help improve care and conditions for patients, families and staff across healthcare systems.

This push has included the establishment of other national patient safety investigation bodies (such as the Norwegian Healthcare Investigation Board, known as UKOM), the expansion into healthcare of other state level investigation bodies (such as the Finnish and Swedish accident investigation bodies), and support gathering for patient safety investigation and oversight bodies in other countries, such as the drive to establish a National Patient Safety Board (NPSB) in the USA.

The first steps toward an international network

On 7 March 2023, HSIB brought together a range of international patient safety investigation agencies for the first time to explore the benefit in building an international network to help share intelligence, best practices and approaches to patient safety investigation.

A second meeting on 19 April 2023 helped to further cement these relationships and begin a process of discussing key risks to patient safety playing out in each country, as well as issues and processes that impact on all investigation bodies around how topics for investigation are identified and how investigations are resourced.

Representatives from a number of countries have now signed up to meet regularly to help build this network, including:

  • England (HSIB)
  • Finland (Safety Investigation Authority)
  • Ireland (Health Service Executive)
  • The Netherlands (Dutch Safety Board)
  • Norway (UKOM)
  • Sweden (Swedish Accident Investigation Authority)
  • USA (NPSB)

A representative from the World Health Organisation was also present to observe the meeting and agencies from other countries such as New Zealand, have already expressed an interest in joining the group as it develops.

The meetings have offered an opportunity for representatives from these organisations to meet to discuss the current state of patient safety investigation in their countries and to share resources to help inform each other’s work.

HSIB was able to share copies of our most recent investigation reports, blogs and the video and feedback from our staff fatigue event, whilst UKOM was able to share an update from their most recent report into treatment of gender dysphoria (which itself references HSIB’s previous work in this area).

The group also heard about the movement to establish a National Patient Safety Board in the USA and the first steps into healthcare incident investigation for Swedish accident investigation colleagues.

Next steps

The network has committed to meeting every quarter and expanding its membership to make sure there are opportunities to share learning across a wider range of countries and patient safety agencies.

There is a desire and commitment for this to lead to greater collaboration and support across this emerging professional community. There is also an ambition to build toward the ability to bring these skills, knowledge and experience together in an international conference to help highlight and support the work of healthcare safety investigation organisations.

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