Patient Safety Incident Investigation (PSII)
General Information
Last updated: July 2026
Next review: July 2028
Understanding Patient Safety Incident Investigations
Patient Safety Incident Investigations (PSIIs) are carried out when a patient safety event requires a detailed review to understand what happened, why it happened and how similar incidents can be prevented in the future.
The purpose of a PSII is not to place blame on individuals. Instead, it focuses on identifying opportunities for learning, improving systems and strengthening patient safety across healthcare services.
Key Points
This page explains how Patient Safety Incident Investigations work, why they are carried out and how patients, families and healthcare professionals can become involved in the investigation process.
On this page you will learn about:
- What a Patient Safety Incident Investigation is.
- Why investigations are undertaken.
- Who carries out a PSII.
- How investigations are conducted.
- How patients, families and carers can contribute.
- How findings lead to improvements in patient safety.
- When a PSII may be appropriate.
- Where to find further information and support.
What Is a Patient Safety Incident Investigation?
A Patient Safety Incident Investigation (PSII) is a structured investigation into an unexpected patient safety event.
The investigation carefully examines the circumstances surrounding the incident to understand why it occurred and identify opportunities to reduce the risk of similar events happening again.
In some cases, a PSII may investigate a series of similar incidents affecting more than one patient to identify wider themes or system improvements.
The primary aim is to improve patient care through learning and continuous improvement.
Why Are Patient Safety Incident Investigations Important?
Patient Safety Incident Investigations help healthcare organisations learn from significant events and strengthen the quality and safety of care.
The objectives of a PSII include:
- Understanding exactly what happened.
- Identifying the underlying factors that contributed to the event.
- Recognising opportunities for improvement.
- Developing practical recommendations to reduce future risk.
- Supporting a culture of openness, learning and continuous improvement.
The focus remains on improving healthcare systems rather than assigning blame to individuals.
Who Carries Out a PSII?
Investigations are led by trained Patient Safety Investigators with expertise in reviewing patient safety events.
During the investigation they may work closely with:
- Clinical teams.
- Healthcare managers.
- Patients.
- Families and carers.
- Other professionals involved in the patient’s care.
Depending on the complexity of the investigation, a PSII may take several weeks or months to complete.
How Does a PSII Work?
Every investigation follows a structured process designed to gather information, understand contributing factors and identify improvements.
Step 1 – Identifying the Need
The Patient Safety Team reviews patient safety events and determines whether a formal investigation is required.
Step 2 – Identifying Those Involved
The investigation team identifies the staff, departments and services connected with the event.
Step 3 – Speaking With Participants
Patients, families, carers and healthcare professionals may be invited to share their experiences and perspectives.
Step 4 – Gathering Information
Relevant clinical records, documentation and other available evidence are carefully reviewed.
Step 5 – Analysing the Event
Investigators examine the information to understand what happened and identify any contributing factors.
Step 6 – Identifying Learning
The investigation explores opportunities to reduce future risk and improve patient safety.
Step 7 – Producing a Report
A detailed report is prepared outlining the findings and recommendations for improvement.
Step 8 – Implementing Improvements
The learning from the investigation is used to improve systems, processes and the quality of future patient care.
How Can Patients and Families Get Involved?
Patients, families and carers can play an important role in helping investigators understand what happened.
You may be invited to:
- Share your experience of the event.
- Provide information that may not be available in clinical records.
- Ask questions throughout the investigation.
- Contribute to improvements that could benefit future patients.
Your perspective helps investigators build a fuller understanding of the incident and supports meaningful learning.
Can I Request a PSII?
Patient Safety Incident Investigations are initiated by the Patient Safety Team following a review of patient safety events.
Not every incident requires a formal investigation. The team carefully considers each event and decides whether a PSII is the most appropriate approach based on the circumstances and the potential learning opportunities.
If you have questions about an investigation or would like further information, you can contact the Patient Safety Team.
Our Commitment to Patient Safety
Patient Safety Incident Investigations are an important part of creating safer healthcare services.
By understanding why incidents occur, involving patients and healthcare professionals, and implementing meaningful improvements, healthcare organisations can continually strengthen the quality of care they provide and help reduce the likelihood of similar events in the future.
Further Information
Patient Safety Incident Investigations are designed to promote learning rather than blame. They provide a structured approach to understanding patient safety events, identifying opportunities for improvement and ensuring that lessons learned lead to safer care for everyone.
