Project title:

Understanding risk.

Type of research:

Mixed methods research.

Background & Strength of Evidence:

Despite excellent efforts from its staff the NHS is sometimes an unsafe system, and currently suffers from an overly reactive stance to the management of safety (Health Foundation, 2012; Ward, 2010). Safety-critical industries place the balance differently between reactive and proactive safety management (e.g. ICAO, 2009). In essence the NHS lacks a proactive, systematic and system-wide stance on risk management (Robinson, 2012; Shebl, 2009; Ward, 2010). This project aimed to readdress the reactive/proactive balance. Risk assessment in the form of a proactive, systematic and holistic approach has been referred to as Prospective Hazard Analysis (PHA) (Ward, 2010). PHA has been little used in healthcare and is a new way of thinking about safety management (Ward, 2010) by taking a systems approach (DH, 2000). Until recently there was a lack of guidance to help NHS staff to perform PHA. To address this need a Toolkit of PHA methods (see BSI, 2010, for more information) was developed through funding from the Department of Health, and was published in a peer-reviewed report in 2010 (Ward, 2010). Through over a dozen evaluations (e.g. Card, 2012), the Toolkit was viewed by NHS staff to be both powerful and usable in helping to identify risk, up-front, before it can cause harm. However it was still in “prototype” form and it was unclear exactly how it should be integrated into the current NHS risk management system as it was not a stand-alone toolkit. This project therefore a) established a more in-depth understanding of how risk management is practised – in the NHS and in other “good practice” safety critical industries, b) developed the toolkit further, c) strengthened its evidence base of use and d) integrated it into risk management practice across the NHS, with an initial focus on the Eastern Region.

Research questions / aims:

This project was split into three Parts.

  • Part 1 developed risk theory, the toolkit and a training package.
  • Part 2 evaluated the toolkit in greater depth than before
  • Part 3 disseminated and integrated new practice into the NHS.

Key Findings and Outputs:

The project developed a toolkit and training package for System Safety Assessment (SSA), a process for examining ‘what could go wrong’ in a healthcare system, helping to prevent problems before they occur. The toolkit is available via the SSA website.

The SSA toolkit was tested as part of a collaborative project ‘Safer Care Pathways in Mental Health’. The project was funded by The Health Foundation, and led by Hertfordshire Partnership University NHS Foundation Trust and aimed to address patient safety hazards in mental health care pathways in five project sites across the East of England. Clinical teams were trained in SSA and also human factors. Evaluation of the project showed that the intervention was effective in supporting the sites to make positive changes to clinical practice. Significant safety culture improvements were found in six out of 12 domains, using an established patient safety culture measure. Training was positively received and there were indications of behavioural change in teams across the project sites. Where data are available, the patient safety improvement projects initiated were associated with moderate decreases in patient safety incidents. Further information about the Safer Care Pathways Project can be found here.

Findings from this project research also significantly informed a study led by the Royal Academy of Engineering which aimed to explore whether an engineering systems approach could be applied in health and care. A preliminary report ‘Engineering better care, a systems approach to health and care design and continuous improvement’ can be downloaded here.

For further information on this project, contact Dr Terry Dickerson at



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