Improving surgical safety through reporting, monitoring and learning

We have launched an investigation that explores how healthcare providers, integrated care boards and national bodies gain assurance about the safety of surgical care through reporting systems, monitoring and learning. Monitoring surgical safety is an important function in healthcare to help identify where surgical outcomes may not be optimal and to help prevent avoidable harm.

This investigation will focus on current monitoring systems and how the information they collect is shared and effectively used to help identify potential issues and drive improvements in surgical safety.

We identified the need for this investigation after engagement with stakeholders, including representatives from national bodies, to seek their insights in relation to patient safety issues associated with surgical safety monitoring.

Surgical safety has been identified by national stakeholders as a key concern and is prominently featured in high profile enquiries where patients have been harmed, and national strategy documents as an area needing improvement.​ However, identifying early signals for surgical safety has often been challenging.

We triangulated this evidence with additional sources including national datasets, national guidance documents and academic literature.

The investigation will seek to understand surgical safety reporting, monitoring and learning in the intraoperative period, including:

• To identify how NHS organisations obtain assurance about surgical safety.
• To examine how information about surgical safety is shared and acted on to improve patient safety, including the impact of team and organisational culture.
• To identify how the NHS and independent sector interact to gather and share information about surgical safety.

We are keen to hear from anybody with an interest in this subject matter. This includes patients, families, carers and health and care professionals who may wish to share their experience.

If you would like to speak to us about this investigation before we publish the final report, please email investigations@hssib.org.uk. Please help us to respond to your email by including details about your interest in the investigation, such as your relevant experience, role, or how you would like to contribute to our work.