Investigations and complaints

Articles in this category

1. Why investigate? Part 11: We have a situation

   • Investigation
   • Human factors
   • (and 3 more)

     Tagged with:

     • Investigation
     • Human factors
     • Situation
     • System safety
     • Human error

   By Graham Edgar, 13 May

   • 0 comments
   • 414 views
   • 
   • Added by Graham Edgar
   • 13 May

2. Why investigate? Part 10: Fatigue – Enter the Sandman

   • Human factors
   • Investigation
   • (and 3 more)

     Tagged with:

     • Human factors
     • Investigation
     • Fatigue / exhaustion
     • Mental health
     • Nutrition

   By Bobbie Enright, 4 April

   • 0 comments
   • 565 views
   • 
   • Added by Bobbie Enright
   • 4 April

3. Why investigate? Part 9: Making wrong decisions when we think they are the right decisions

   • Investigation
   • Confirmation bias
   • (and 2 more)

     Tagged with:

     • Investigation
     • Confirmation bias
     • Decision making
     • Human factors

   By Prof Alex Stedmon, 9 March

   • 0 comments
   • 557 views
   • 
   • Added by Prof Alex Stedmon
   • 9 March

4. Why investigate: Part 8 – Why an ‘It’s an error trap conclusion’ is an error trap

   • Investigation
   • Human error
   • (and 2 more)

     Tagged with:

     • Investigation
     • Human error
     • Human factors
     • Regulatory issue

   By MartinL, 17 February

   • 0 comments
   • 677 views
   • 
   • Added by MartinL
   • 17 February

5. Raising concerns about a healthcare worker (AvMA)

   • Investigation
   • Complaint
   • (and 1 more)

     Tagged with:

     • Investigation
     • Complaint
     • Negligence claim

   By PatientSafetyLearning Team, 2 February

   • 0 comments
   • 105 views
   • 
   • Added by PatientSafetyLearning Team
   • 2 February

6. Self-help guides: Action Against Medical Accidents (AvMA)

   • Complaint
   • Investigation
   • (and 1 more)

     Tagged with:

     • Complaint
     • Investigation
     • Patient harmed

   By PatientSafetyLearning Team, 1 February

   • 0 comments
   • 96 views
   • 
   • Added by PatientSafetyLearning Team
   • 1 February

7. CQC inspections and regulation of Whorlton Hall: second independent report (15 December 2020)

   • Legal issue
   • Patient safety incident
   • (and 8 more)

     Tagged with:

     • Legal issue
     • Patient safety incident
     • Recommendations
     • Regulatory issue
     • Learning disabilities
     • Autism
     • Organisational culture
     • Organisational Performance
     • Organisational learning
     • Speaking up

   By Patient Safety Learning, 6 January

   • 0 comments
   • 218 views
   • 
   • Added by Patient Safety Learning
   • 6 January

8. Why investigate? Part 7 – The questions and answers

   • Investigation
   • Human factors
   • (and 1 more)

     Tagged with:

     • Investigation
     • Human factors
     • Safety assessment

   By MartinL, 8 December, 2020

   • 0 comments
   • 731 views
   • 
   • Added by MartinL
   • 8 December, 2020

9. HSIB: Submit a patient safety concern

   • Complaint
   • Patient engagement
   • (and 1 more)

     Tagged with:

     • Complaint
     • Patient engagement
     • Safety report

   By PatientSafetyLearning Team, 30 September, 2020

   • 0 comments
   • 281 views
   • 
   • Added by PatientSafetyLearning Team
   • 30 September, 2020

10. Radio Ombudsman #19: Sir Robert Francis QC on why listening to patients is vital to improve services

    • Complaint
    • Speaking up
    • (and 3 more)

      Tagged with:

      • Complaint
      • Speaking up
      • Whistleblowing
      • Patient engagement
      • Accountability

    By Patient Safety Learning, 16 September, 2020

    • 0 comments
    • 378 views
    • 
    • Added by Patient Safety Learning
    • 16 September, 2020

11. Findings of the Cumberlege Review: patient complaints

    • Womens health
    • Complaint
    • (and 2 more)

      Tagged with:

      • Womens health
      • Complaint
      • Patient harmed
      • Patient engagement

    By PatientSafetyLearning Team, 30 July, 2020

    • 0 comments
    • 838 views
    • 
    • Added by PatientSafetyLearning Team
    • 30 July, 2020

12. Healthcare regulation should be about the people, not the process (July 2020)

    • Investigation
    • Patient engagement
    • (and 5 more)

      Tagged with:

      • Investigation
      • Patient engagement
      • Patient death
      • Baby
      • Maternity
      • Quality improvement
      • Patient involvement

    By PatientSafetyLearning Team, 30 July, 2020

    • 0 comments
    • 395 views
    • 
    • Added by PatientSafetyLearning Team
    • 30 July, 2020

13. Restorative practice in healthcare (webinar recording, July 2020)

    • Investigation
    • Safety culture
    • (and 4 more)

      Tagged with:

      • Investigation
      • Safety culture
      • Culture of fear
      • Transparency
      • Leadership
      • Restorative Justice

    By Claire Cox, 27 July, 2020

    • 0 comments
    • 379 views
    • 
    • Added by Claire Cox
    • 27 July, 2020

14. Race differences in reported harmful patient safety events in healthcare system high reliability organisations (December 2018)

    • Race
    • Ethnicity
    • (and 3 more)

      Tagged with:

      • Race
      • Ethnicity
      • Health inequalities
      • Discrimination
      • Unconscious bias

    By PatientSafetyLearning Team, 27 July, 2020

    • 0 comments
    • 187 views
    • 
    • Added by PatientSafetyLearning Team
    • 27 July, 2020

15. ‘Requiring immediate action’: The patient safety issues hidden in unpublished reports (25 June 2020)

    • Investigation
    • Patient safety incident
    • (and 6 more)

      Tagged with:

      • Investigation
      • Patient safety incident
      • Organisational culture
      • Communication
      • Maternity
      • Surgery - General
      • Bullying
      • Patient death

    By Patient Safety Learning, 26 June, 2020

    • 0 comments
    • 781 views
    • 
    • Added by Patient Safety Learning
    • 26 June, 2020

16. How or Why. Part 6. A series of blogs from Dr Martin Langham

    • Investigation
    • Indicators
    • (and 4 more)

      Tagged with:

      • Investigation
      • Indicators
      • Ergonomics
      • Contributing factor
      • External factors
      • Perception / understanding

    By MartinL, 5 June, 2020

    • 2 comments
    • 1,635 views
    • 
    • Comment by Patient Safety Learning
    • 10 June, 2020

17. The patient died: What about involvement in the investigation process? (May 2020)

    • Patient
    • Patient death
    • (and 2 more)

      Tagged with:

      • Patient
      • Patient death
      • Patient / family involvement
      • Investigation

    By Claire Cox, 26 May, 2020

    • 0 comments
    • 568 views
    • 
    • Added by Claire Cox
    • 26 May, 2020

18. Incident review report: COVID-19 staff infections Waitakere Hospital (April 2020)

    • Investigation
    • Staff safety
    • (and 4 more)

      Tagged with:

      • Investigation
      • Staff safety
      • PPE (personal Protective Equipment)
      • Care home
      • Transmission
      • Virus

    By Claire Cox, 13 May, 2020

    • 0 comments
    • 863 views
    • 
    • Added by Claire Cox
    • 13 May, 2020

19. CQC inspections and regulation of Whorlton Hall 2015-2019: an independent review (18 February 2020)

    • Recommendations
    • Regulatory issue
    • (and 7 more)

      Tagged with:

      • Recommendations
      • Regulatory issue
      • Legal issue
      • Learning disabilities
      • Autism
      • Organisational learning
      • Organisational culture
      • Speaking up
      • Patient safety incident

    By Patient Safety Learning, 6 May, 2020

    • 0 comments
    • 114 views
    • 
    • Added by Patient Safety Learning
    • 6 May, 2020

20. When to investigate? Part 5. A series of blogs from Dr Martin Langham

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

      Tagged with:

      • Investigation
      • Patient safety incident
      • Contributing factor
      • Recommendations
      • Teamwork

    By MartinL, 4 March, 2020

    • 2 comments
    • 1,376 views
    • 
    • Comment by Patient Safety Learning
    • 5 March, 2020

21. House of Commons – Maternity Services: East Kent (13 February 2020)

    • Maternity
    • Baby
    • (and 2 more)

      Tagged with:

      • Maternity
      • Baby
      • Investigation
      • Patient death

    By PatientSafetyLearning Team, 17 February, 2020

    • 0 comments
    • 455 views
    • 
    • Added by PatientSafetyLearning Team
    • 17 February, 2020

22. Bevan Brittan Patient Safety Seminar: Incident investigation. A new approach (January 2020)

    • Investigation
    • Patient safety incident
    • (and 4 more)

      Tagged with:

      • Investigation
      • Patient safety incident
      • Legal issue
      • Training
      • Patient / family involvement
      • Patient engagement

    By Patient Safety Learning, 8 February, 2020

    • 0 comments
    • 257 views
    • 
    • Added by Patient Safety Learning
    • 8 February, 2020

23. Human factors – the scientific study of man in her built environment. Part 4 of the ‘why investigate’ series

    • Investigation
    • Human error
    • (and 3 more)

      Tagged with:

      • Investigation
      • Human error
      • Assessment and Recommendation
      • Contributing factor
      • Physical environment

    By MartinL, 23 January, 2020

    • 2 comments
    • 1,279 views
    • 
    • Comment by Patient Safety Learning
    • 11 February, 2020

24. Podcast: How a communication error and subsequent medication mix up led to the death of a patient (December 2019)

    • Investigation
    • Recommendations
    • (and 2 more)

      Tagged with:

      • Investigation
      • Recommendations
      • Communication problems
      • Medication

    By Patient Safety Learning, 17 December, 2019

    • 0 comments
    • 579 views
    • 
    • Added by Patient Safety Learning
    • 17 December, 2019

25. Who should investigate? Part 3. A series of blogs from Dr Martin Langham

    • Investigation
    • Contributing factor
    • (and 2 more)

      Tagged with:

      • Investigation
      • Contributing factor
      • Assessment and Recommendation
      • Teamwork

    By MartinL, 12 November, 2019

    • 1 comment
    • 1,184 views
    • 
    • Comment by Patient Safety Learning
    • 12 November, 2019