Investigations, risk management and legal issues

Articles in this category

1. Action Against Medical Accidents (AvMA): What you need to know about AvMA

   • Patient
   • Patient harmed
   • (and 4 more)

     Tagged with:

     • Patient
     • Patient harmed
     • Complaint
     • Investigation
     • Legal issue
     • Patient / family involvement

   By Mark Hughes, 15 July

   • 0 comments
   • 83 views
   • 
   • Added by Mark Hughes
   • 15 July

2. Causes and conditions in patient safety

   • Investigation
   • Just Culture

   By PatientSafetyLearning Team, 18 June

   • 0 comments
   • 204 views
   • 
   • Added by PatientSafetyLearning Team
   • 18 June

3. Systems-based models for investigating patient safety incidents (28 April 2021)

   • Investigation
   • System safety
   • (and 2 more)

     Tagged with:

     • Investigation
     • System safety
     • Patient safety incident
     • Systems modelling

   By Patient Safety Learning, 6 May

   • 1 comment
   • 370 views
   • 
   • Comment by Keith Bates
   • 6 May

4. Once for Wales Concerns Management System

   • Patient safety incident
   • Quality improvement
   • (and 5 more)

     Tagged with:

     • Patient safety incident
     • Quality improvement
     • Complaint
     • Digital health
     • Legal issue
     • Risk management
     • Reporting

   By Patient Safety Learning, 20 April

   • 0 comments
   • 83 views
   • 
   • Added by Patient Safety Learning
   • 20 April

5. First Global Patient Safety Network Webinar 2021 - Patient safety incident reporting and learning systems (5 March 2021)

   • Patient safety incident
   • Reporting
   • (and 2 more)

     Tagged with:

     • Patient safety incident
     • Reporting
     • Organisational learning
     • Quality improvement

   By Patient Safety Learning, 15 April

   • 0 comments
   • 151 views
   • 
   • Added by Patient Safety Learning
   • 15 April

6. 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

   • 4 comments
   • 2,341 views
   • 
   • Comment by Dominic Stenning
   • 16 July

7. 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
   • 287 views
   • 
   • Added by Patient Safety Learning
   • 9 September, 2020

8. “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
   • 6,916 views
   • 
   • Comment by PatientSafetyLearning Team
   • 25 September, 2020

9. 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
   • 856 views
   • 
   • Added by Steve Turner
   • 6 September, 2020

10. 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
    • 340 views
    • 
    • Added by Patient Safety Learning
    • 3 September, 2020

11. 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
    • 251 views
    • 
    • Added by Patient Safety Learning
    • 1 September, 2020

12. 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
    • 587 views
    • 
    • Added by PatientSafetyLearning Team
    • 26 August, 2020

13. The importance of near miss reporting

    • Reporting
    • Near miss

    By Claire Cox, 4 August, 2020

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

14. 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
    • 572 views
    • 
    • Added by Patient Safety Learning
    • 2 June, 2020

15. 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
    • 129 views
    • 
    • Added by Patient Safety Learning
    • 11 May, 2020

16. BMJ: Government’s response to £239m worth of inquiries has been “opaque,” says NAO (24 May 2018)

    • Investigation
    • Research

    By Patient Safety Learning, 7 May, 2020

    • 0 comments
    • 99 views
    • 
    • Added by Patient Safety Learning
    • 7 May, 2020

17. 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
    • 528 views
    • 
    • Added by PatientSafetyLearning Team
    • 7 February, 2020

18. 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
    • 334 views
    • 
    • Added by Claire Cox
    • 4 February, 2020

19. 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
    • 309 views
    • 
    • Added by PatientSafetyLearning Team
    • 5 January, 2020

20. 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
    • 412 views
    • 
    • Added by lzipperer
    • 29 November, 2019

21. 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
    • 353 views
    • 
    • Added by lzipperer
    • 3 November, 2019

22. 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
    • 741 views
    • 
    • Added by lzipperer
    • 29 October, 2019

23. 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
    • 456 views
    • 
    • Added by Patient Safety Learning
    • 22 October, 2019

24. 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
    • 391 views
    • 
    • Added by PatientSafetyLearning Team
    • 11 October, 2019

25. 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
    • 614 views
    • 
    • Comment by Eva Applications
    • 11 December, 2019