Investigating for improvement? Five strategies to ensure national patient safety investigations improve patient safety.

Macrae C. J R Soc Med. 2019 May 22; [Epub ahead of print].

Incident investigations present important opportunities for process examination and redesign. This commentary recommends five strategies to ensure investigations inform patient safety improvement. The author emphasizes a focus on system risks, redesigning systems, examination process transparency, public accountability, and consideration of patient, family, and staff experiences.

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