Action plans and applying recommendations from investigations

Articles in this category

1. When Learning from Deaths doesn’t really learn: Research summary by Dr Zoe Brummell

   • Organisational learning
   • Patient death
   • (and 2 more)

     Tagged with:

     • Organisational learning
     • Patient death
     • PSIRF
     • Patient / family involvement

   By Patient Safety Learning, 21 April

   • 0 comments
   • 210 views
   • 
   • Added by Patient Safety Learning
   • 21 April

2. The Safety of Work podcast: Ep.48 What are the missing links between investigating incidents and learning from incidents? (11 October 2020)

   • Investigation
   • Patient safety incident
   • (and 1 more)

     Tagged with:

     • Investigation
     • Patient safety incident
     • Organisational learning

   By Patient Safety Learning, 2 October, 2025

   • 0 comments
   • 238 views
   • 
   • Added by Patient Safety Learning
   • 2 October, 2025

3. Do patient safety incident investigations align with systems thinking? An analysis of contributing factors and recommendations (12 September 2025)

   • Investigation
   • Organisational learning
   • (and 3 more)

     Tagged with:

     • Investigation
     • Organisational learning
     • Recommendations
     • Research
     • System safety

   By Patient Safety Learning, 1 October, 2025

   • 0 comments
   • 378 views
   • 
   • Added by Patient Safety Learning
   • 1 October, 2025

4. Dr Bill Kirkup CBE: Learning lessons from past enquiries (FabStuff podcast, 12 July 2025)

   • Investigation
   • Organisational learning
   • (and 2 more)

     Tagged with:

     • Investigation
     • Organisational learning
     • Maternity
     • Patient death

   By Patient Safety Learning, 23 July, 2025

   • 0 comments
   • 272 views
   • 
   • Added by Patient Safety Learning
   • 23 July, 2025

5. Systems analysis of clinical incidents: the London Protocol 2024

   • Organisational learning
   • Patient safety incident

   By Patient Safety Learning, 9 July, 2025

   • 0 comments
   • 421 views
   • 
   • Added by Patient Safety Learning
   • 9 July, 2025

6. NHS Education for Scotland: Learning Response Review Tool

   • Organisational learning
   • Patient safety incident
   • (and 3 more)

     Tagged with:

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

   By Patient Safety Learning, 16 April, 2025

   • 0 comments
   • 917 views
   • 
   • Added by Patient Safety Learning
   • 16 April, 2025

7. Learning from every death (March 2014)

   • Patient death
   • Organisational learning
   • (and 2 more)

     Tagged with:

     • Patient death
     • Organisational learning
     • Research
     • Reporting

   By Patient Safety Learning, 11 December, 2024

   • 0 comments
   • 363 views
   • 
   • Added by Patient Safety Learning
   • 11 December, 2024

8. A review of deaths in surgery using the structured judgement case note review process (31 May 2023)

   • Investigation
   • Organisational learning
   • (and 1 more)

     Tagged with:

     • Investigation
     • Organisational learning
     • Surgery - General

   By Patient Safety Learning, 20 November, 2024

   • 0 comments
   • 368 views
   • 
   • Added by Patient Safety Learning
   • 20 November, 2024

9. NHS England: Learning from deaths in the NHS

   • Organisational learning
   • Patient death
   • (and 2 more)

     Tagged with:

     • Organisational learning
     • Patient death
     • Quality improvement
     • Implementation

   By Patient Safety Learning, 20 November, 2024

   • 0 comments
   • 400 views
   • 
   • Added by Patient Safety Learning
   • 20 November, 2024

10. Exploring the “black box” of recommendation generation in local health care incident investigations: A scoping review (15 September 2023)

    • Investigation
    • Organisational learning
    • (and 6 more)

      Tagged with:

      • Investigation
      • Organisational learning
      • Recommendations
      • Follow up
      • Scoping review
      • Patient safety incident
      • Root cause anaylsis
      • Quality improvement

    By Patient Safety Learning, 29 September, 2023

    • 0 comments
    • 892 views
    • 
    • Added by Patient Safety Learning
    • 29 September, 2023

11. National Infection Prevention and Control Manual: Hot debriefing template (2017)

    • PSIRF
    • Infection control
    • (and 3 more)

      Tagged with:

      • PSIRF
      • Infection control
      • Patient safety incident
      • Reporting
      • Organisational learning

    By Patient Safety Learning, 22 June, 2023

    • 0 comments
    • 850 views
    • 
    • Added by Patient Safety Learning
    • 22 June, 2023

12. Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report (2 May 2023)

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

      Tagged with:

      • PSIRF
      • Patient safety incident
      • Investigation
      • Human factors
      • System safety
      • Quality improvement

    By Patient Safety Learning, 23 May, 2023

    • 0 comments
    • 1,089 views
    • 
    • Added by Patient Safety Learning
    • 23 May, 2023

13. Disaster recovery: restoring hope after things go wrong (Judy Walker, 5 January 2023)

    • After action review
    • Organisational learning
    • (and 4 more)

      Tagged with:

      • After action review
      • Organisational learning
      • Organisational culture
      • Implementation
      • Recommendations
      • Personal reflection

    By Patient-Safety-Learning, 20 January, 2023

    • 0 comments
    • 790 views
    • 
    • Added by Patient-Safety-Learning
    • 20 January, 2023

14. Thinking thematically: top tips for completing a thematic review (NHS England, August 2022)

    • PSIRF
    • Recommendations
    • (and 2 more)

      Tagged with:

      • PSIRF
      • Recommendations
      • Investigation
      • Organisational learning

    By Patient Safety Learning, 17 October, 2022

    • 0 comments
    • 1,759 views
    • 
    • Added by Patient Safety Learning
    • 17 October, 2022

15. CQC: Learning from safety incidents (22 April 2022)

    • Regulatory issue
    • Quality improvement
    • (and 10 more)

      Tagged with:

      • Regulatory issue
      • Quality improvement
      • Organisational learning
      • Patient safety incident
      • Sepsis
      • Medication
      • Falls
      • Medical device / equipment
      • Patient harmed
      • Older People (over 65)
      • Consent
      • Sexual and reproductive health

    By Sam, 4 June, 2022

    • 0 comments
    • 1,149 views
    • 
    • Added by Sam
    • 4 June, 2022

16. Improvement Academy: Yorkshire Contributory Factors Framework

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

      Tagged with:

      • Investigation
      • Patient safety incident
      • Organisational learning
      • Human factors

    By Patient Safety Learning, 5 November, 2021

    • 0 comments
    • 2,486 views
    • 
    • Added by Patient Safety Learning
    • 5 November, 2021

17. Swarm: a quick and efficient response to patient safety incidents (21 August 2017)

    • Patient safety incident
    • Investigation
    • (and 5 more)

      Tagged with:

      • Patient safety incident
      • Investigation
      • Root cause anaylsis
      • Organisational learning
      • Organisational culture
      • Falls
      • Innovation

    By Patient Safety Learning, 22 October, 2021

    • 0 comments
    • 2,367 views
    • 
    • Added by Patient Safety Learning
    • 22 October, 2021

18. Philippa Dodshon - Practitioners' experiences as incident investigators in the field (4 September 2020)

    • Investigation
    • Patient safety incident
    • (and 1 more)

      Tagged with:

      • Investigation
      • Patient safety incident
      • Organisational learning

    By Patient Safety Learning, 12 May, 2021

    • 0 comments
    • 819 views
    • 
    • Added by Patient Safety Learning
    • 12 May, 2021

19. Chartered Institute of Ergonomics & Human Factors (CIEHF): White Paper: Learning from adverse events (24 June 2020)

    • Organisational learning
    • Investigation
    • (and 4 more)

      Tagged with:

      • Organisational learning
      • Investigation
      • System safety
      • Patient safety incident
      • Recommendations
      • Safety culture

    By Patient Safety Learning, 24 June, 2020

    • 0 comments
    • 3,331 views
    • 
    • Added by Patient Safety Learning
    • 24 June, 2020

20. Investigations and making safe decisions (podcast)

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

      Tagged with:

      • Paramedic
      • Patient safety incident
      • Leadership
      • Information sharing

    By Claire Cox, 28 April, 2020

    • 0 comments
    • 1,292 views
    • 
    • Added by Claire Cox
    • 28 April, 2020

21. David Rowland: The Paterson inquiry is a missed opportunity to tackle systemic patient safety risks in private healthcare (February 2020)

    • Private sector
    • Surgeon
    • (and 6 more)

      Tagged with:

      • Private sector
      • Surgeon
      • Recommendations
      • Patient safety incident
      • Patient safety strategy
      • Risk assessment
      • Investigation
      • Root cause anaylsis

    By Patient Safety Learning, 22 February, 2020

    • 0 comments
    • 1,438 views
    • 
    • Added by Patient Safety Learning
    • 22 February, 2020

22. Infection control – norovirus outbreak: Action plan (2016–2017)

    • Health hazards
    • Safety management
    • (and 8 more)

      Tagged with:

      • Health hazards
      • Safety management
      • Organisational learning
      • Workspace design
      • Workforce management
      • Labelling / packaging/ signage
      • Risk assessment
      • Action plan
      • Risk management
      • Physical environment

    By Claire Cox, 15 August, 2019

    • 0 comments
    • 1,733 views
    • 
    • Added by Claire Cox
    • 15 August, 2019

23. Action plan of a treatment delay (2017–2018)

    • Patient
    • Accident and Emergency
    • (and 12 more)

      Tagged with:

      • Patient
      • Accident and Emergency
      • HDU / ICU
      • Treatment
      • Emergency medicine
      • Mental health - adult
      • Clinical process
      • Blood / blood products
      • Near miss
      • Information processing
      • Additional treatment / tests
      • Policies / Protocols / Procedures
      • Retrospective
      • Patient safety incident

    By Claire Cox, 15 August, 2019

    • 0 comments
    • 1,765 views
    • 
    • Added by Claire Cox
    • 15 August, 2019

24. NHS England: Business continuity management toolkit – case studies (19 October 2017)

    • Action plan
    • Risk management
    • (and 7 more)

      Tagged with:

      • Action plan
      • Risk management
      • Patient safety incident
      • Organisational learning
      • Safety management
      • Reporting
      • Risk assessment
      • Organisation / service factors
      • System safety

    By Patient Safety Learning, 26 June, 2019

    • 0 comments
    • 1,356 views
    • 
    • Added by Patient Safety Learning
    • 26 June, 2019

25. Guide for NHS trusts on local learning from deaths policies (October 2017)

    • Post mortem
    • Patient death
    • (and 4 more)

      Tagged with:

      • Post mortem
      • Patient death
      • Safety process
      • Organisational learning
      • Training
      • Resource allocation

    By Claire Cox, 4 October, 2017

    • 0 comments
    • 1,315 views
    • 
    • Added by Claire Cox
    • 4 October, 2017