The fundamental purpose of a patient safety investigation is to learn from the incident, and not to apportion blame. Examining incidents and events in a structured way allows the detail of events to be uncovered systematically, drawing out learning.
It is vital through a rigorous investigation to establish clear causes and contributory factors. This will ensure that the correct recommendations are made and the appropriate actions result in long-term sustainable change where future harm will be prevented. It is also imperative that healthcare services have robust mechanisms to ensure learning is implemented and embedded into practice; ensuring that mindful learning occurs.
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