Action plans and applying recommendations from investigations

Articles in this category

1. 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

   • 0 comments
   • 64 views
   • 
   • Added by Patient-Safety-Learning
   • 20 January

2. Example of a PSIRF preparation guide

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

     Tagged with:

     • PSIRF
     • Patient safety incident
     • Action plan
     • Staff support

   By Patient Safety Learning, 25 October, 2022

   • 0 comments
   • 1,007 views
   • 
   • Added by Patient Safety Learning
   • 25 October, 2022

3. 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
   • 170 views
   • 
   • Added by Patient Safety Learning
   • 17 October, 2022

4. PSIRF tool: Themed review template (August 2022)

   • PSIRF
   • Investigation
   • (and 4 more)

     Tagged with:

     • PSIRF
     • Investigation
     • Patient safety incident
     • Impact analysis
     • Risk assessment
     • System safety

   By Patient Safety Learning, 14 October, 2022

   • 0 comments
   • 812 views
   • 
   • Added by Patient Safety Learning
   • 14 October, 2022

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

   • Regulatory issue
   • Quality improvement
   • (and 8 more)

     Tagged with:

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

   By Sam, 4 June, 2022

   • 0 comments
   • 145 views
   • 
   • Added by Sam
   • 4 June, 2022

6. PSIRF: A framework for achieving effective learning and improvement (NHSE/I, 18 May 2022)

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

     Tagged with:

     • Investigation
     • Patient safety incident
     • Organisational learning
     • Organisational culture
     • PSIRF

   By Patient Safety Learning, 26 May, 2022

   • 0 comments
   • 536 views
   • 
   • Added by Patient Safety Learning
   • 26 May, 2022

7. North Bristol NHS Trust: Patient Safety Incident Response Plan

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

     Tagged with:

     • Patient safety incident
     • Investigation
     • Organisational learning
     • Organisational culture
     • Safety process

   By Patient Safety Learning, 25 May, 2022

   • 0 comments
   • 364 views
   • 
   • Added by Patient Safety Learning
   • 25 May, 2022

8. 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
   • 906 views
   • 
   • Added by Patient Safety Learning
   • 5 November, 2021

9. 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
   • 724 views
   • 
   • Added by Patient Safety Learning
   • 22 October, 2021

10. What HSIB has learned about the need for an organised approach to safety? (presentation 16 September 2021)

    • Investigation
    • Recommendations

    By Patient Safety Learning, 10 October, 2021

    • 0 comments
    • 360 views
    • 
    • Added by Patient Safety Learning
    • 10 October, 2021

11. 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
    • 220 views
    • 
    • Added by Patient Safety Learning
    • 12 May, 2021

12. 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
    • 1,942 views
    • 
    • Added by Patient Safety Learning
    • 24 June, 2020

13. 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
    • 707 views
    • 
    • Added by Claire Cox
    • 28 April, 2020

14. 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
    • 844 views
    • 
    • Added by Patient Safety Learning
    • 22 February, 2020

15. 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
    • 1,035 views
    • 
    • Added by Claire Cox
    • 15 August, 2019

16. 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
    • 1,012 views
    • 
    • Added by Claire Cox
    • 15 August, 2019

17. 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
    • 731 views
    • 
    • Added by Patient Safety Learning
    • 26 June, 2019

18. 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
    • 713 views
    • 
    • Added by Claire Cox
    • 4 October, 2017