Published last week in Safety Science, the framework identifies 38 competencies that separate effective investigators from those who simply go through the motions. The research reveals a fundamental shift in what investigators need:
- Technical expertise in investigation methods.
- Personal qualities such as empathy, independence and rigour.
- The ability to involve patients and families meaningfully throughout an investigation.
- Understanding how complex healthcare systems actually work in practice, not just how they are supposed to work on paper.
- The ability to identify the aspects that contribute to unsafe healthcare such as workload pressures, poorly designed processes or incompatible technology.
- The ability to identify areas for system improvement.
Globally, almost three million people die each year due to unsafe healthcare. In England alone, the economic cost of unsafe care is estimated at £14.7 billion annually. Without skilled investigators capable of uncovering the range of factors that contribute to unsafe healthcare, the same incidents will continue to repeat and patients will remain at risk.
Dr Rosemary Lim, Senior Investigation Science Educator at HSSIB and lead author of the study, said: “The 'blame and retrain' approach for frontline workers involved in healthcare incidents is old news. Yet investigations have continued to focus on individual fault because, until now, there has been no agreed set of competencies anywhere in the world defining what skilled investigators should actually do instead.
“Inconsistent investigations often miss the scope of contributory factors when healthcare goes wrong such as impossible workloads, poorly designed systems, or incompatible technology, and instead default to blaming individuals or recommending superficial fixes like retraining staff.
“Our study makes clear that investigators need more than technical expertise to ensure patient safety. The right combination of skills, knowledge and personal qualities is essential if we are to prevent the same harm happening to patients, families and staff again and again."
The research involved 28 experts, including practising investigators, educators and policymakers, who took part in a rigorous two-round consultation process to reach consensus on what defines competent investigation practice.
HSSIB co-led the research with The University of Reading.
Related articles
Education team present safety investigator competencies work at annual human factors conference
Read article
