Action plans and applying recommendations from investigations

Articles in this category

1. 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

   • 0 comments
   • 310 views
   • 
   • Added by Patient Safety Learning
   • 16 April

2. 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
   • 171 views
   • 
   • Added by Patient Safety Learning
   • 11 December, 2024

3. 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
   • 149 views
   • 
   • Added by Patient Safety Learning
   • 20 November, 2024

4. 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
   • 168 views
   • 
   • Added by Patient Safety Learning
   • 20 November, 2024

5. 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
   • 667 views
   • 
   • Added by Patient Safety Learning
   • 29 September, 2023

6. 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
   • 651 views
   • 
   • Added by Patient Safety Learning
   • 22 June, 2023

7. 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
   • 813 views
   • 
   • Added by Patient Safety Learning
   • 23 May, 2023

8. 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
   • 640 views
   • 
   • Added by Patient-Safety-Learning
   • 20 January, 2023

9. 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
   • 1,341 views
   • 
   • Added by Patient Safety Learning
   • 17 October, 2022

10. 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
    • 815 views
    • 
    • Added by Sam
    • 4 June, 2022

11. 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
    • 2,110 views
    • 
    • Added by Patient Safety Learning
    • 5 November, 2021

12. 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
    • 1,854 views
    • 
    • Added by Patient Safety Learning
    • 22 October, 2021

13. 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
    • 687 views
    • 
    • Added by Patient Safety Learning
    • 12 May, 2021

14. 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
    • 3,032 views
    • 
    • Added by Patient Safety Learning
    • 24 June, 2020

15. 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
    • 1,156 views
    • 
    • Added by Claire Cox
    • 28 April, 2020

16. 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
    • 1,288 views
    • 
    • Added by Patient Safety Learning
    • 22 February, 2020

17. 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
    • 1,575 views
    • 
    • Added by Claire Cox
    • 15 August, 2019

18. 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
    • 1,606 views
    • 
    • Added by Claire Cox
    • 15 August, 2019

19. 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
    • 1,207 views
    • 
    • Added by Patient Safety Learning
    • 26 June, 2019

20. 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
    • 1,181 views
    • 
    • Added by Claire Cox
    • 4 October, 2017