This course has passed.


The establishment of the Healthcare Safety Investigation Branch (HSIB) in April 2017 and the draft Health Service Safety Investigations Bill, places a renewed emphasis on investigating breaches of patient safety. By fully understanding the responsibilities and actions necessary for dealing with Serious Incidents and the tools available, healthcare professionals will be able to enhance patient safety.

By attending this Improving Patient Safety Investigations course, delegates will learn how to utilise human factors analysis to investigate patient safety; gain an insight into the structure of an investigation and learn how to communicate the results of the investigation to the patient and their families.

Delegates on this interactive course will improve how they conduct and communicate patient safety investigations with Dr Suzanne Shale,  HSIB Advisory Panel Member and Chair of the Action against Medical Accidents.

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Learning Outcomes

  • Work with NHS Resolution to improve the quality of your investigations
  • Utilise Human Factors to gain an holistic view of the investigation
  • Learn from best practice to successfully carry out an investigation
  • Be aware of the implications of the Draft Health Service Safety Investigations Bill
  • Create an action plan to improve how your organisation conducts investigations
All the Understanding ModernGov courses are Continuing Professional Development (CPD) certified, with signed certificates available upon request for event.

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09:15 - 09:45


09:45 - 10:00

Chair's Welcome and Clarification of Learning Objectives

10:00 - 10:45

How to Improve the Quality of Local Investigations

  • Understand which are the main barriers to learning from incidents
  • Assess how to promote a system which instils confidence and drives improvements in safety
  • Focus on how to create a culture of learning and accountability and not blame
10:45 - 11:00

Morning Break

11:00 - 12:00

Utilise Human Factors to Successfully Carry out an Investigation

  • Understand how human factors analysis can help identify and mitigate human error across organisational systems
  • Compare the Human Factors Analysis, Classification System (HFACS) and the Yorkshire Contributory Factors Framework
  • Discuss challenges to developing systemic solutions to problems
12:00 - 13:00

Patient Safety Investigation in Action

  • Learn best practice at carrying out an investigation
  • Train staff to successfully investigate accidents
  • Establish effective governance principles to support investigations
  • Support staff involved in the Serious Incident Investigations
13:00 - 14:00


14:00 - 14:45

Effectively Engage with Patients and Families

  • Use patient perspectives to improve accuracy of findings
  • Provide support to patients and families, and understand the role of advocates/advisers
  • Understand the Duty of Candour in the context of investigations
  • Learn how to adequately communicate findings from investigations
14:45 - 15:00

Afternoon Break

15:00 - 16:00

Workshop: Drive Improvements in Patient Safety

  • Review the impact of the Draft Patient Safety Investigation Bill on local investigations
  • Understand the developments of the consultation regarding “safe spaces”
  • Enable meaningful engagement with patients and families
  • Discuss how to engage senior leaders in responding to complex patient safety issues identified in investigations
16:00 - 16:15

Feedback, Evaluation & Close


etc. Venues – The Hatton, London

51-53 Hatton Garden Clerkenwell, London, EC1N 8HN