Investigations, risk management and legal issues

Articles in this category

1. English and Welsh Ombudsman set out the case for '... a proper public inquiry into the tragic death of Robbie Powell'

   • Police
   • Post mortem
   • (and 15 more)

     Tagged with:

     • Police
     • Post mortem
     • Harmed Care Pathway
     • Medicine - Diabetes and Endocrinology
     • Patient death
     • Competence
     • Criminal behaviour
     • System safety
     • Leadership
     • Organisational culture
     • Organisational learning
     • Whistleblowing
     • Transparency
     • Patient engagement
     • Children and Young People
     • Investigation
     • Coroner reports

   By Steve Turner, 17 November, 2020

   • 2 comments
   • 443 views
   • 
   • Comment by Steve Turner
   • Sunday at 11:26

2. What Never Events on PHIN's website can tell you about hospitals (2 September 2020)

   • Never event
   • Checklists
   • (and 2 more)

     Tagged with:

     • Never event
     • Checklists
     • Patient
     • Private sector

   By Patient Safety Learning, 9 September, 2020

   • 0 comments
   • 178 views
   • 
   • Added by Patient Safety Learning
   • 9 September, 2020

3. “I’m going to Datix you”

   • Patient safety incident
   • Reporting
   • (and 3 more)

     Tagged with:

     • Patient safety incident
     • Reporting
     • Software
     • Culture of fear
     • Organisational culture

   By Jonathan, 7 September, 2020

   • 2 comments
   • 4,254 views
   • 
   • Comment by Claire Cox
   • 25 September, 2020

4. The history of Duty Of Candour and why Robbie's Law matters

   • Patient death
   • Patient harmed
   • (and 4 more)

     Tagged with:

     • Patient death
     • Patient harmed
     • Duty of Candour
     • Patient safety / risk management leads
     • Clinical governance
     • Ethics

   By Steve Turner, 6 September, 2020

   • 0 comments
   • 470 views
   • 
   • Added by Steve Turner
   • 6 September, 2020

5. Private Healthcare Information Network: Publication of provisional Never Events for the reporting period 1st January 2019 and 31st December 2019

   • Never event
   • Private sector

   By Patient Safety Learning, 3 September, 2020

   • 0 comments
   • 215 views
   • 
   • Added by Patient Safety Learning
   • 3 September, 2020

6. Patient Safety Learning: Confusion over PPE guidance poses a patient safety risk (27 August 2020)

   • PPE (personal Protective Equipment)
   • Virus
   • (and 3 more)

     Tagged with:

     • PPE (personal Protective Equipment)
     • Virus
     • Pandemic
     • Care home
     • Recommendations

   By Patient Safety Learning, 1 September, 2020

   • 0 comments
   • 165 views
   • 
   • Added by Patient Safety Learning
   • 1 September, 2020

7. RCN: Top 10 tips for statement writing

   • Staff support
   • Investigation
   • (and 2 more)

     Tagged with:

     • Staff support
     • Investigation
     • Reporting
     • Nurse

   By PatientSafetyLearning Team, 26 August, 2020

   • 0 comments
   • 231 views
   • 
   • Added by PatientSafetyLearning Team
   • 26 August, 2020

8. The importance of near miss reporting

   • Reporting
   • Near miss

   By Claire Cox, 4 August, 2020

   • 0 comments
   • 89 views
   • 
   • Added by Claire Cox
   • 4 August, 2020

9. The Duty of Candour – where are we now? (30 January 2020)

   • Duty of Candour
   • Accountability
   • (and 3 more)

     Tagged with:

     • Duty of Candour
     • Accountability
     • Organisational culture
     • Organisational learning
     • Transparency

   By Patient Safety Learning, 2 June, 2020

   • 0 comments
   • 353 views
   • 
   • Added by Patient Safety Learning
   • 2 June, 2020

10. Healthcare Quality Quest: Root Cause Analysis (2019)

    • Root cause anaylsis
    • Risk assessment
    • (and 2 more)

      Tagged with:

      • Root cause anaylsis
      • Risk assessment
      • Investigation
      • Quality improvement

    By Patient Safety Learning, 11 May, 2020

    • 0 comments
    • 49 views
    • 
    • Added by Patient Safety Learning
    • 11 May, 2020

11. Peter Duffy podcast: safety critical issues remain at UHMBT

    • Investigation
    • Patient death
    • (and 4 more)

      Tagged with:

      • Investigation
      • Patient death
      • Whistleblowing
      • Bullying
      • Culture of fear
      • Accountability

    By PatientSafetyLearning Team, 7 February, 2020

    • 0 comments
    • 351 views
    • 
    • Added by PatientSafetyLearning Team
    • 7 February, 2020

12. The problem with incident reporting by Carl Macrae (7 September 2015)

    • Investigation
    • Reporting
    • (and 1 more)

      Tagged with:

      • Investigation
      • Reporting
      • Patient safety / risk management leads

    By Claire Cox, 4 February, 2020

    • 0 comments
    • 226 views
    • 
    • Added by Claire Cox
    • 4 February, 2020

13. Ely Hospital, Cardiff: Inquiry findings (1969)

    • Investigation
    • Staff factors
    • (and 3 more)

      Tagged with:

      • Investigation
      • Staff factors
      • Nurse
      • Standards
      • Patient safety incident

    By PatientSafetyLearning Team, 5 January, 2020

    • 0 comments
    • 185 views
    • 
    • Added by PatientSafetyLearning Team
    • 5 January, 2020

14. Review of alternatives to root cause analysis: developing a robust system for incident report analysis (BMJ Open Quality, August 2019)

    • Root cause anaylsis
    • Benchmarking

    By lzipperer, 29 November, 2019

    • 0 comments
    • 320 views
    • 
    • Added by lzipperer
    • 29 November, 2019

15. AHRQ: Rethinking root cause analysis (January 2016)

    • Root cause analysis
    • Investigation
    • (and 1 more)

      Tagged with:

      • Root cause analysis
      • Investigation
      • Safety assessment

    By lzipperer, 3 November, 2019

    • 0 comments
    • 253 views
    • 
    • Added by lzipperer
    • 3 November, 2019

16. RCA2: Improving root cause analyses and actions to prevent harm (National Patient Safety Foundation, 2015)

    • Root cause analysis
    • Organisational learning

    By lzipperer, 29 October, 2019

    • 0 comments
    • 418 views
    • 
    • Added by lzipperer
    • 29 October, 2019

17. Presentation: Effective learning from serious incidents. Experience from the Patient Safety Academy (16 October 2019)

    • Investigation
    • Training
    • (and 2 more)

      Tagged with:

      • Investigation
      • Training
      • Quality improvement
      • Patient safety incident

    By Patient Safety Learning, 22 October, 2019

    • 0 comments
    • 342 views
    • 
    • Added by Patient Safety Learning
    • 22 October, 2019

18. NHS Improvement: reporting patient safety incidents in general practice (2017)

    • GP practice
    • Risk management
    • (and 3 more)

      Tagged with:

      • GP practice
      • Risk management
      • Patient safety incident
      • Reporting
      • Near miss

    By PatientSafetyLearning Team, 11 October, 2019

    • 0 comments
    • 272 views
    • 
    • Added by PatientSafetyLearning Team
    • 11 October, 2019

19. Eva Applications: what does a good quality investigation look like and how can it be achieved? (September 2019)

    • Process redesign
    • Investigation
    • (and 1 more)

      Tagged with:

      • Process redesign
      • Investigation
      • Quality improvement

    By Eva Applications, 9 October, 2019

    • 1 comment
    • 430 views
    • 
    • Comment by Eva Applications
    • 11 December, 2019

20. Yorkshire Contributory Factors Framework (YCFF)

    • Investigation
    • Contributing factor
    • (and 3 more)

      Tagged with:

      • Investigation
      • Contributing factor
      • Patient safety incident
      • Patient safety strategy
      • Decision making

    By PatientSafetyLearning Team, 1 October, 2019

    • 0 comments
    • 883 views
    • 
    • Added by PatientSafetyLearning Team
    • 1 October, 2019

21. How the Parliamentary and Health Service Ombudsman (PHSO) looks into complaints

    • Complaint
    • Policies / Protocols / Procedures
    • (and 1 more)

      Tagged with:

      • Complaint
      • Policies / Protocols / Procedures
      • Reporting

    By Claire Cox, 25 September, 2019

    • 0 comments
    • 285 views
    • 
    • Added by Claire Cox
    • 25 September, 2019

22. What is the Healthcare Safety Investigation Branch (HSIB)?

    • Investigation
    • Patient safety incident
    • (and 3 more)

      Tagged with:

      • Investigation
      • Patient safety incident
      • Recommendations
      • Quality improvement
      • Organisational learning

    By Claire Cox, 12 September, 2019

    • 0 comments
    • 301 views
    • 
    • Added by Claire Cox
    • 12 September, 2019

23. About Action Against Medical Accidents (AvMA)

    • Patient
    • Near miss
    • (and 6 more)

      Tagged with:

      • Patient
      • Near miss
      • Patient death
      • Patient harmed
      • Complaint
      • Investigation
      • Legal issue
      • Patient / family involvement

    By Patient Safety Learning, 8 September, 2019

    • 0 comments
    • 252 views
    • 
    • Added by Patient Safety Learning
    • 8 September, 2019

24. NHS Inquiries and Investigations; an Exemplar in Peculiarity and Assumption

    • Qualitative
    • Investigation
    • (and 3 more)

      Tagged with:

      • Qualitative
      • Investigation
      • Quality improvement
      • Recommendations
      • Patient / family involvement

    By Claire Cox, 4 July, 2019

    • 0 comments
    • 326 views
    • 
    • Added by Claire Cox
    • 4 July, 2019

25. The future of NHS patient safety investigation: engagement feedback (November 2018)

    • Quality improvement
    • Patient safety incident
    • (and 4 more)

      Tagged with:

      • Quality improvement
      • Patient safety incident
      • Qualitative
      • Quantative
      • Questionnaire
      • Patient / family involvement

    By Patient Safety Learning, 26 June, 2019

    • 0 comments
    • 310 views
    • 
    • Added by Patient Safety Learning
    • 26 June, 2019