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A red electrocardiogram
A red electrocardiogram
A red electrocardiogram

Navigating & Enhancing Patient Safety Through HSS Inclusive Investigations

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The Health Services Safety Investigations Body (HSSIB) recently published a comprehensive report underscoring a crucial aspect of healthcare delivery within the NHS: the involvement of temporary staff in patient safety investigations. As the NHS leans heavily on temporary clinical staff to bridge workforce gaps, the report shines a light on the systemic challenges and offers actionable recommendations to ensure these vital contributors are integral to improving patient safety outcomes.


The Underlying Challenges

Temporary staff, including bank, agency staff, and locum doctors, play a pivotal role in the NHS’s daily operations. However, the HSSIB's investigation reveals that the engagement of these staff members in patient safety investigations is often limited, posing a risk to the depth and effectiveness of learning from incidents. The report outlines several barriers to their involvement, ranging from logistical challenges, such as access to incident reporting systems, to procedural issues, like the lack of direct communication channels.


Key Findings

  1. Limited Involvement in Safety Investigations: The exclusion of temporary staff from patient safety investigations restricts the learning potential and weakens the foundation for future safety enhancements.

  2. Barriers to Reporting Incidents: Temporary staff face obstacles in reporting safety incidents, impacting the development of an open reporting culture crucial for learning and improvement.

  3. Variability in Feedback and Learning Dissemination: There's an inconsistency in how findings from investigations are communicated back to temporary staff, hindering the collective learning process.

  4. Inadequate Support Post-Incident: Temporary staff often receive less support following safety incidents, affecting their welfare and potentially patient safety.

  5. Framework Agreements Lacking Reference to Patient Safety: Current NHS England framework agreements for agency staff do not explicitly address patient safety or the support for staff following safety incidents.


Recommendations for a Safer Future

The HSSIB’s recommendations are a clarion call for systemic changes to better integrate temporary staff into the patient safety ecosystem. Key recommendations include:

  • Enhanced Guidance for Involving Temporary Staff: NHS England is urged to include specific guidance on engaging temporary staff in learning responses following a patient safety incident. This effort should involve collaboration with temporary staff providers to ensure comprehensive incident investigations and learning.

  • Updating Framework Agreement Criteria: The agency worker framework agreement criteria should be revised to mandate adherence to the NHS England Patient Safety Incident Response Framework's staff support principles, recognising the link between staff wellbeing and patient care delivery.

  • Facilitating Involvement in Investigation Processes: Agencies providing temporary staff to the NHS can enhance patient safety by easing the participation of these staff in investigation processes, including interviews, in line with the Patient Safety Incident Response Framework.


A Path Forward

The HSSIB report serves as a vital blueprint for rethinking how temporary staff are integrated into the processes that safeguard patient welfare. By addressing the highlighted challenges and implementing the proposed recommendations, the NHS can bolster its patient safety framework, ensuring that every member of the healthcare team, regardless of their employment status, is empowered and equipped to contribute to safer patient care.

This call to action is not just about procedural adjustments; it’s a fundamental shift towards a more inclusive, learning-oriented culture within the NHS, where every voice is heard, and every experience is valued in the continuous journey towards excellence in patient safety.


The insights and recommendations from the HSSIB's investigation into the involvement of temporary staff in patient safety investigations illuminate a critical aspect of healthcare delivery that requires immediate attention. As the NHS evolves, the integration of temporary staff into the fabric of patient safety investigations will be paramount in fostering a culture of continuous learning and improvement.


A photo of Scott Harding-Lister, Director at Apex Health Associates


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