Investigations, risk management and legal issues

Articles in this category

1. The importance of near miss reporting

   • Reporting
   • Near miss

   By Claire Cox, Tuesday at 11:15

   • 0 comments
   • 13 views
   • 
   • Added by Claire Cox
   • Tuesday at 11:15

2. 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, February 7

   • 0 comments
   • 140 views
   • 
   • Added by PatientSafetyLearning Team
   • February 7

3. The problem with incident reporting

   • Investigation
   • Reporting
   • (and 1 more)

     Tagged with:

     • Investigation
     • Reporting
     • Patient safety / risk management leads

   By Claire Cox, February 4

   • 0 comments
   • 126 views
   • 
   • Added by Claire Cox
   • February 4

4. 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, January 5

   • 0 comments
   • 114 views
   • 
   • Added by PatientSafetyLearning Team
   • January 5

5. 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, November 29, 2019

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

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

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

     Tagged with:

     • Root cause analysis
     • Investigation
     • Safety assessment

   By lzipperer, November 3, 2019

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

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

   • Root cause analysis
   • Organisational learning

   By lzipperer, October 29, 2019

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

8. 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, October 22, 2019

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

9. The problem with incident reporting

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

     Tagged with:

     • Investigation
     • Patient safety incident
     • Organisational learning
     • Organisational Performance
     • NRLS

   By Patient Safety Learning, October 22, 2019

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

10. 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, October 11, 2019

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

11. 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, October 9, 2019

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

12. 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, October 1, 2019

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

13. 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, September 25, 2019

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

14. 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, September 12, 2019

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

15. 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, September 8, 2019

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

16. 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, July 4, 2019

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

17. 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, June 26, 2019

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

18. Regulation 20: Duty of Candour (8 June 2017)

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

      Tagged with:

      • Duty of Candour
      • Accountability
      • Safety culture
      • Reporting
      • Regulatory issue

    By Patient Safety Learning, June 26, 2019

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

19. NHS Improvement: Root cause analysis - using five whys (17 January 2018)

    • Root cause anaylsis

    By Patient Safety Learning, May 22, 2019

    • 0 comments
    • 65 views
    • 
    • Added by Patient Safety Learning
    • May 22, 2019