Advancing Patient Safety: A cross-system thematic review in Wessex

I joined Health Innovation Wessex in 2024 as a Patient Safety Programme Manager, coming from a national patient safety investigation body, where I was a Safety Insights Analyst. My career in the NHS began in 2016 as a healthcare assistant whilst completing a BSc in Adult Nursing and subsequently an MSc in Ergonomics and Human Factors, but my safety career actually began more than 20 years ago in commercial aviation as a maritime surveillance pilot, Flight Safety Manager and Human Factors Instructor. In my current role I support NHS providers and commissioners across Wessex (Dorset, and Hampshire and Isle of Wight) with national patient safety programmes in system safety and deterioration that are informed by the NHS Patient Safety Strategy.

There are around 600 million patient interactions within the NHS per year, with approximately 3,000 resulting in a safety investigation (DHSC 2025). Investigations are carried out to learn from incidents and to make changes that should prevent the same thing from happening to someone else.

The Patient Safety Incident Response Framework (PSIRF) was officially launched nationally in August 2022 and replaced the Serious Incident framework which focused on the level of harm to a patient or staff member. PSIRF has transformed the response to incidents, with organisations able to use a variety of tools, such as a multidisciplinary team (MDT) huddle, an After Action Review or a patient safety incident investigation, to identify learning by understanding the many factors leading to an incident.

Once all Wessex organisations had successfully implemented PSIRF for a year or more, there was a fantastic opportunity to bring together their data and identify whether investigations from different organisations would contain common factors that had contributed to the incidents. If so, the results could inform system-wide improvement projects enabling joined up working by multiple organisations, avoiding repetition of time and effort by individual organisations and people.

Health Innovation Wessex Insights team received 27 anonymised investigation reports from ten Wessex organisations including acute trusts, ambulance trusts and independent providers. The reports were thematically analysed, and interestingly many common factors were found, leading to the identification of three themes:

• communication
• system-level factors (e.g. technology or environment)
• workforce.

From this review we made four recommendations:

• build on existing improvement initiatives
• identify gaps in current processes
• routinely adopt a thematic review of PSIIs
• replicate the review in other regions.

Health Innovation Wessex, Wessex providers and the Integrated Care Boards are using the review findings to develop system-wide improvement and learning. We have received some valuable and positive feedback from the organisations involved, below is a small snapshot:

‘Following the thematic review, we are reviewing our internal learning from discharges based on the system learning identified’. Liz Hall, Head of Patient Safety and Learning, Hampshire and Isle of Wight Healthcare.

‘The review has contributed significantly to our oversight of providers in Dorset and insight into shared areas for improvement’. Jaydee Swarbrick, Head of Patient Safety, NHS Dorset.

‘It has led to further thought on what actions have been successfully embedded in areas outside maternity that could be replicated locally’. Julie Comer, Safety and Quality Lead, Southampton, Hampshire, Isle of Wight and Portsmouth Local Maternity and Neonatal System.

It has been great to work with system partners to bring together expert knowledge and experience in patient safety to coordinate improvement efforts that can have a much wider impact, preventing harm and improving systems for both patients and clinicians.

Watch our short video to hear more about this work:

Discover more about our work on System Safety and read the full review.

For further information, or if you are interested in a PSII thematic review in your region, please contact us on patient.safety@hiwessex.net