Methodology and guidance: How to do an investigation

Articles in this category

1. Accelerated learning through AAR (Judy Walker, 3 May 2023)

   • After action review
   • Investigation
   • (and 5 more)

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     • After action review
     • Investigation
     • Organisational learning
     • Communication
     • Team culture
     • Near miss
     • Never event

   By Patient-Safety-Learning, 24 May, 2023

   • 0 comments
   • 1,080 views
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   • Added by Patient-Safety-Learning
   • 24 May, 2023

2. Significant Event Audit guidance (RCGP Patient Safety Toolkit)

   • Audit
   • Investigation
   • (and 3 more)

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     • Audit
     • Investigation
     • GP
     • Patient safety incident
     • Organisational learning

   By Patient-Safety-Learning, 1 May, 2023

   • 0 comments
   • 1,047 views
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   • Added by Patient-Safety-Learning
   • 1 May, 2023

3. Learn Together: Investigation resources

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

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     • Investigation
     • Patient safety incident
     • Patient harmed
     • Patient / family involvement
     • Patient / family support
     • Staff support
     • PSIRF
     • Collaboration

   By Patient Safety Learning, 12 December, 2022

   • 0 comments
   • 1,204 views
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   • Added by Patient Safety Learning
   • 12 December, 2022

4. Using appreciative inquiry to transform health care (August 2013)

   • Appreciative inquiry
   • Innovation
   • (and 3 more)

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     • Appreciative inquiry
     • Innovation
     • Transformation
     • Quality improvement
     • Australia

   By Patient-Safety-Learning, 9 December, 2022

   • 0 comments
   • 817 views
   • 
   • Added by Patient-Safety-Learning
   • 9 December, 2022

5. CAST Tutorial: STAMP approach to accident analysis (26 March 2013)

   • Investigation
   • Just Culture
   • (and 3 more)

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     • Investigation
     • Just Culture
     • System safety
     • Process redesign
     • Aviation

   By Patient-Safety-Learning, 13 August, 2022

   • 0 comments
   • 1,122 views
   • 
   • Added by Patient-Safety-Learning
   • 13 August, 2022

6. AcciMap: Promoting systems thinking in accident investigations and system design

   • System safety
   • Investigation
   • (and 1 more)

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     • System safety
     • Investigation
     • Patient safety incident

   By Patient Safety Learning, 19 April, 2022

   • 0 comments
   • 2,372 views
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   • Added by Patient Safety Learning
   • 19 April, 2022

7. NHS England Patient safety incident investigation tools

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

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     • Patient safety incident
     • Patient harmed
     • Investigation

   By Patient-Safety-Learning, 14 October, 2021

   • 0 comments
   • 5,637 views
   • 
   • Added by Patient-Safety-Learning
   • 14 October, 2021

8. The transformation of accident investigation: From finding cause to sense making (2015)

   • Investigation
   • Methodology
   • (and 3 more)

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     • Investigation
     • Methodology
     • USA
     • Leadership
     • Organisational learning

   By Patient Safety Learning, 26 May, 2021

   • 0 comments
   • 1,571 views
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   • Added by Patient Safety Learning
   • 26 May, 2021

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

   • Investigation
   • System safety
   • (and 2 more)

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

   By Patient Safety Learning, 6 May, 2021

   • 1 comment
   • 3,023 views
   • 
   • Comment by Keith Bates
   • 6 May, 2021

10. Guidelines for AcciMap analysis (January 2009)

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

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      • Investigation
      • Patient safety incident
      • System safety
      • Aviation

    By Patient Safety Learning, 21 March, 2021

    • 0 comments
    • 2,439 views
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    • Added by Patient Safety Learning
    • 21 March, 2021

11. ‘Remixing Rasmussen’: The evolution of Accimaps within systemic accident analysis

    • Investigation
    • Research
    • (and 5 more)

      Tagged with:

      • Investigation
      • Research
      • Methodology
      • Patient accident
      • System safety
      • Link analysis
      • Human factors

    By Patient Safety Learning, 18 March, 2021

    • 0 comments
    • 1,333 views
    • 
    • Added by Patient Safety Learning
    • 18 March, 2021

12. RCA2: Improving root cause analyses and actions to prevent harm

    • Investigation
    • Root cause anaylsis
    • (and 1 more)

      Tagged with:

      • Investigation
      • Root cause anaylsis
      • Methodology

    By Patient Safety Learning, 15 March, 2021

    • 0 comments
    • 5,344 views
    • 
    • Added by Patient Safety Learning
    • 15 March, 2021

13. NHS Wales: Framework for the joint investigation of patient safety Serious Incidents (SIs) related to NWIS delivered or supported services

    • Healthcare
    • Patient safety incident
    • (and 10 more)

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      • Healthcare
      • Patient safety incident
      • Policies / Protocols / Procedures
      • Safety process
      • Patient safety / risk management leads
      • Digital health
      • Investigation
      • Root cause anaylsis
      • Never event
      • Near miss
      • Patient death
      • Patient harmed

    By Gethin, 24 January, 2021

    • 0 comments
    • 1,694 views
    • 
    • Added by Gethin
    • 24 January, 2021

14. Root cause analysis: Why we need to change the focus

    • Investigation
    • Root cause anaylsis
    • (and 1 more)

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      • Investigation
      • Root cause anaylsis
      • Quality improvement

    By Jerome P, 7 October, 2020

    • 10 comments
    • 15,616 views
    • 
    • Comment by Jon Holt
    • 20 October, 2020

15. NEBOSH HSE introduction to incident investigation

    • Root cause anaylsis
    • Investigation
    • (and 2 more)

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      • Root cause anaylsis
      • Investigation
      • Patient safety incident
      • Training

    By Patient Safety Learning, 22 January, 2020

    • 0 comments
    • 1,579 views
    • 
    • Added by Patient Safety Learning
    • 22 January, 2020

16. What you find is not always what you fix—How other aspects than causes of accidents decide recommendations for remedial actions (Novemeber 2010)

    • Qualitative
    • Investigation
    • (and 1 more)

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      • Qualitative
      • Investigation
      • System safety

    By Claire Cox, 4 December, 2019

    • 0 comments
    • 1,144 views
    • 
    • Added by Claire Cox
    • 4 December, 2019

17. Improvement Academy. Investigating Patient Safety - Evidence Based Framework

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

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      • Investigation
      • Patient safety incident
      • Policies / Protocols / Procedures

    By Patient Safety Learning, 28 October, 2019

    • 0 comments
    • 2,159 views
    • 
    • Added by Patient Safety Learning
    • 28 October, 2019

18. ROSPA: Accident investigation training

    • Investigation
    • Root cause anaylsis
    • (and 1 more)

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      • Investigation
      • Root cause anaylsis
      • Training

    By Patient Safety Learning, 22 October, 2019

    • 0 comments
    • 1,390 views
    • 
    • Added by Patient Safety Learning
    • 22 October, 2019

19. CQC briefing: learning from serious incidents in NHS acute hospitals (May 2017)

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

      Tagged with:

      • Recommendations
      • Patient safety incident
      • Investigation
      • Patient involvement
      • Contributing factor
      • Organisational learning

    By PatientSafetyLearning Team, 13 October, 2019

    • 0 comments
    • 1,522 views
    • 
    • Added by PatientSafetyLearning Team
    • 13 October, 2019

20. Using the structured judgement review method: A guide for reviewers (2016)

    • Patient death
    • Process redesign
    • (and 3 more)

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      • Patient death
      • Process redesign
      • Confidence
      • Training
      • Case report

    By Claire Cox, 6 October, 2019

    • 2 comments
    • 8,232 views
    • 
    • Comment by Patient Safety Learning
    • 7 May

21. Safety analysis over time: Seven major changes to adverse event investigation

    • Safety process
    • Safety management
    • (and 2 more)

      Tagged with:

      • Safety process
      • Safety management
      • Process redesign
      • Impact anaylsis

    By Claire Cox, 23 September, 2019

    • 0 comments
    • 1,413 views
    • 
    • Added by Claire Cox
    • 23 September, 2019

22. Presentation on Root Cause Analysis and Just Culture: A practical application to drive improvement (March 2019)

    • Accountability
    • Organisational learning
    • (and 4 more)

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      • Accountability
      • Organisational learning
      • Just Culture
      • Leadership
      • Root cause analysis
      • Risk management

    By Patient Safety Learning, 26 June, 2019

    • 0 comments
    • 1,214 views
    • 
    • Added by Patient Safety Learning
    • 26 June, 2019

23. NHS National Clinical Assessment Service: Case investigator training programme: Sample Investigation Report (25 March 2013)

    • Investigation
    • Training

    By Patient Safety Learning, 26 June, 2019

    • 0 comments
    • 1,207 views
    • 
    • Added by Patient Safety Learning
    • 26 June, 2019

24. Investigation Policy and Procedure - Sussex Partnership NHS Foundation Trust (October 2018, v.3)

    • Just Culture
    • Accountability
    • (and 2 more)

      Tagged with:

      • Just Culture
      • Accountability
      • Investigation
      • Policies / Protocols / Procedures

    By Patient Safety Learning, 26 June, 2019

    • 0 comments
    • 2,125 views
    • 
    • Added by Patient Safety Learning
    • 26 June, 2019

25. Patient and family engagement in incident investigations: exploring hospital manager and incident investigators’ experiences and challenges (October 2018)

    • Communication
    • User-centred design
    • (and 2 more)

      Tagged with:

      • Communication
      • User-centred design
      • Qualitative
      • Patient involvement

    By Patient Safety Learning, 26 June, 2019

    • 0 comments
    • 1,128 views
    • 
    • Added by Patient Safety Learning
    • 26 June, 2019