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Managing the after effects of serious patient safety incidents in the NHS: an online survey study
  1. Anna Pinto,
  2. Omar Faiz,
  3. Charles Vincent
  1. Division of Surgery, Department of Surgery & Cancer, St Mary's Campus, Imperial College London, London, UK
  1. Correspondence to Anna Pinto, Division of Surgery, Department of Surgery & Cancer, Imperial College London, St Mary's Campus, Norfolk Place, London W2 1PG, UK; a.pinto{at}


Objective To examine the current state of practice in English NHS Trusts in relation to the communication of serious patient safety incidents to patients and families and support for all parties involved.

Design Cross-sectional design using online surveys.

Participants 209 patient safety managers, responsible for the ‘Being Open’ policy (54% response rate).

Setting English NHS Trusts.

Results 98% of the participants reported that they are familiar with the National Patient Safety Agency Being Open guidance and 82% that they implement it more than half the time when incidents occur. However, provision of timely information was not reported as routine, with two-thirds of the discussions taking place 3–6 weeks after the investigation. The frequency of taking responsibility for harm was low for incidents of different severity levels but significantly lower for less serious ones (p<0.001). Follow-ups of patients in the long term and ex gratia payments were provided less than half the time. The most highly rated barriers to being open were clinical staff's fear of negative reactions from patients or their families and anxiety about litigation. Support practices for staff, such as debriefing and training on being open, were acknowledged as highly important but not always available.

Conclusions Awareness of the importance of being open is high among patient safety managers in English NHS Trusts, but there is still considerable scope for improvement in the management of the after effects of patient safety incidents. More research is needed on patients' and healthcare professionals' preferences for support after patient safety incidents.

  • Patient safety
  • adverse events
  • being open
  • second victim
  • risk management

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  • Funding This work was supported by funding from the Health Foundation. The Imperial Centre for Patient Safety and Service Quality is funded by the UK National Institute for Health Research (NIHR).

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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