Background The National Patient Safety Agency estimates 850,000 adverse incidents and errors occur annually in the NHS (NPSA. About the NPSA. [internet]). Each incident/error has consequences to patients and people in their lives, and staff involved (Care Quality Commission. Opening the door to change NHS safety culture and the need for transformation. 2018; National Patient Safety Agency. About the NPSA. [internet]). In January 2022 the In-Patient Unit decided to incorporate human factors (HF) to our reporting system to establish in-depth analysis of incidents, enabling us to understand why they occur thus fostering a psychologically safe culture for staff.

Aim To audit accidents and incidents relating to medication on the in-patient unit only.

Methods Mixed methods approach comprising data from April 2022 - March 2023.

Qualitative Data -Two surveys sent to Investigators, Registered Nurses, and Assistant Practitioners. Surveys were divided amongst investigators and staff involved in investigation process.

Quantitative Data -Three incidents were randomly chosen each month. Auditor looked at documentation to answer the following questions - Were human factors identified? Which human factors were identified? Was the investigator able to identify what happened and why? Was learning identified? What was the impact on staff? Total number of records examined were 36. Total number of incidents during this period were 56.

Results Themes highlighted the need for ongoing development of measures to support staff wellbeing and a person-centred culture. Research by the Society of Occupational Medicine found that 40% of nurses reported ‘often’ or ‘always’ feeling burned out.

Conclusion Since the introduction of human factors into investigations of incidents, qualitative data gathered demonstrates that it has been beneficial for investigators and reporters. There has been a change of attitudes where incidents are ‘explored’ rather than investigated which can be perceived as punitive. This approach focuses on learning from incidents, staff wellbeing when incidents occur, and the impact staff wellbeing plays in preventing incidents whilst improving patient safety. Our findings are aligned with ‘Patient Safety Incident Response Framework’ (PSIRF) principles we are implementing (NHS England. Patient Safety Incident Response Framework. [internet]).