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A Patient Safety Incident Investigation (PSII) was initiated following a norovirus outbreak on the adult inpatient unit. The investigation, supported by After Action Reviews and the Systems Engineering Initiative for Patient Safety (SEIPS) framework, enabled a thorough evaluation of existing systems and processes. It also highlighted effective measures which prevented further spread due to the measures put in place.The PSII aimed to understand what happened, why it happened, and how to prevent recurrence, using a systems-based, non-blame approach focused on learning and improvement. Alongside identifying areas for change, the investigation celebrated successful interventions.Three After Action Reviews were conducted to capture lessons from both positive and negative outcomes. These reviews allowed staff – both directly and indirectly involved – to share their lived experiences and suggest improvements in a safe, open environment.A comprehensive review of policies, procedures, infection control practices, and outbreak response pathways was undertaken. This included evaluating roles and responsibilities and collaborating with system partners, such as the Integrated Care Board’s Infection Prevention and Control team. As a small provider without dedicated infection prevention and control nurses, their expert guidance was invaluable. Using the SEIPS framework, the organisation examined key work system elements: environment, people, tasks, tools, and organisational structure. This holistic approach helped identify both effective practices and areas for improvement to enhance patient and staff safety. Key changes included updates to policies and procedures, the creation of an outbreak pack, and improved signage for infection prevention and control outbreaks. Annual outbreak training for infection prevention and control champions will also be introduced.Finally, the findings and outcomes from the PSII were shared across the hospice and the wider Mid and South Essex Hospice Collaborative. The use of structured investigation tools enabled us to improve our systems while also recognising and celebrating what went well during the outbreak response.