Our Patient Safety Incident response plan: Incidents that don’t fall into the outlined national or local PSII categories

8.1 CHS will take a proportionate response to patient safety incidents in order to maximise learning. Where an investigation is deemed appropriate, a “systems based approach” to learning will be applied. This means that investigations will focus on examining the components of the “work system” (eg person(s), tasks, tools and technology, the environment, the wider organisation) and understanding their interdependencies & those interdependencies may contribute to patient safety. As such, different learning responses & investigation techniques will be adopted to all patient safety incidents, depending on the intended aim and required outcome.

8.2 The response to Patient Falls, Pressure Ulcers and nosocomial Covid-19 deaths includes a Trust wide improvement plan which will be updated with any new learning identified from associated incidents / case reviews. These will be led by the subject matter experts and monitored through the relevant groups with oversight through the governance structure.