Investigations, risk management and legal issues

Articles in this category

1. AvMA case study: Baby E's story

   • Maternity
   • Labour
   • (and 7 more)

     Tagged with:

     • Maternity
     • Labour
     • Staff factors
     • Additional staff required
     • Midwife
     • Monitoring
     • Patient death
     • Baby
     • Coroner

   By Patient-Safety-Learning, 4 October, 2022

   • 0 comments
   • 1,033 views
   • 
   • Added by Patient-Safety-Learning
   • 4 October, 2022

2. AvMA case study: K's story

   • Medicine - Respiratory
   • Diagnostic error
   • (and 6 more)

     Tagged with:

     • Medicine - Respiratory
     • Diagnostic error
     • Care record
     • Electronic Health Record
     • Patient death
     • Coroner
     • Older People (over 65)
     • Chronic obstructive pulmonary disease

   By Patient-Safety-Learning, 30 September, 2022

   • 0 comments
   • 1,176 views
   • 
   • Added by Patient-Safety-Learning
   • 30 September, 2022

3. AvMA case study: M's story

   • Asthma
   • Children and Young People
   • (and 5 more)

     Tagged with:

     • Asthma
     • Children and Young People
     • Patient death
     • Prescribing
     • Human error
     • GP
     • Coroner

   By Patient-Safety-Learning, 29 September, 2022

   • 0 comments
   • 1,090 views
   • 
   • Added by Patient-Safety-Learning
   • 29 September, 2022

4. AvMA case study: Glyn's story

   • Legal issue
   • Patient death
   • (and 5 more)

     Tagged with:

     • Legal issue
     • Patient death
     • Pneumonia
     • Disability
     • Transparency
     • Autism
     • Organisational learning

   By Patient-Safety-Learning, 27 September, 2022

   • 0 comments
   • 1,027 views
   • 
   • Added by Patient-Safety-Learning
   • 27 September, 2022

5. AvMA case study: Richard's story

   • Medicine - Palliative
   • End of life care
   • (and 5 more)

     Tagged with:

     • Medicine - Palliative
     • End of life care
     • Older People (over 65)
     • Medication
     • Pain
     • Patient death
     • Coroner

   By Patient-Safety-Learning, 27 September, 2022

   • 0 comments
   • 855 views
   • 
   • Added by Patient-Safety-Learning
   • 27 September, 2022

6. AvMA case study: Ruth's story

   • Maternity
   • Patient harmed
   • (and 3 more)

     Tagged with:

     • Maternity
     • Patient harmed
     • Baby
     • Legal issue
     • Disability

   By Patient-Safety-Learning, 6 September, 2022

   • 0 comments
   • 875 views
   • 
   • Added by Patient-Safety-Learning
   • 6 September, 2022

7. HSIB blog - Integrating restorative justice into patient safety investigation (29 July 2022)

   • Restorative Justice
   • Investigation
   • (and 3 more)

     Tagged with:

     • Restorative Justice
     • Investigation
     • Patient harmed
     • Patient engagement
     • Second victim

   By Patient-Safety-Learning, 3 August, 2022

   • 0 comments
   • 1,065 views
   • 
   • Added by Patient-Safety-Learning
   • 3 August, 2022

8. General Pharmaceutical Council. Keeping patients safe: being open and honest when things go wrong

   • Pharmacist
   • Duty of Candour
   • (and 3 more)

     Tagged with:

     • Pharmacist
     • Duty of Candour
     • Transparency
     • Patient safety incident
     • Investigation

   By Patient Safety Learning, 29 June, 2022

   • 0 comments
   • 983 views
   • 
   • Added by Patient Safety Learning
   • 29 June, 2022

9. Blog - Patient Safety Never Events in the NHS (16 June 2022)

   • Never event
   • Data
   • (and 3 more)

     Tagged with:

     • Never event
     • Data
     • Safety report
     • Patient harmed
     • UK

   By Patient-Safety-Learning, 28 June, 2022

   • 0 comments
   • 1,117 views
   • 
   • Added by Patient-Safety-Learning
   • 28 June, 2022

10. Bodies of Evidence: The Butcher Surgeon (12 June 2022)

    • Cancer
    • Patient harmed
    • (and 4 more)

      Tagged with:

      • Cancer
      • Patient harmed
      • Surgery - General
      • Legal issue
      • Patient safety incident
      • Investigation

    By Patient-Safety-Learning, 13 June, 2022

    • 0 comments
    • 1,744 views
    • 
    • Added by Patient-Safety-Learning
    • 13 June, 2022

11. Westminster Confidential: Judge covers up “avoidable death” of heart patient and General Medical Council revalidation of Dr Usha Prasad to dismiss her whistleblowing case (13 March 2022)

    • Whistleblowing
    • Patient harmed
    • (and 3 more)

      Tagged with:

      • Whistleblowing
      • Patient harmed
      • Legal issue
      • Transparency
      • Investigation

    By Patient Safety Learning, 21 April, 2022

    • 0 comments
    • 1,001 views
    • 
    • Added by Patient Safety Learning
    • 21 April, 2022

12. Registration and management of 'Never Events' in Swiss hospitals—the perspective of clinical risk managers (December 2021)

    • Never event
    • Switzerland
    • (and 3 more)

      Tagged with:

      • Never event
      • Switzerland
      • Risk management
      • Patient safety / risk management leads
      • Patient safety incident

    By Patient-Safety-Learning, 2 March, 2022

    • 0 comments
    • 1,324 views
    • 
    • Added by Patient-Safety-Learning
    • 2 March, 2022

13. Open letter to the Rt Hon Jeremy Hunt MP: 'Coronavirus Lessons Learned Inquiry' – a missed opportunity

    • PPE (personal Protective Equipment)
    • Infection control
    • (and 6 more)

      Tagged with:

      • PPE (personal Protective Equipment)
      • Infection control
      • Staff safety
      • Virus
      • Pandemic
      • Investigation
      • Legal issue
      • Regulatory issue

    By SafeDavid3, 25 February, 2022

    • 0 comments
    • 1,121 views
    • 
    • Added by SafeDavid3
    • 25 February, 2022

14. COVID-19: Witness evidence submitted to the Commons Select Committee

    • PPE (personal Protective Equipment)
    • Infection control
    • (and 6 more)

      Tagged with:

      • PPE (personal Protective Equipment)
      • Infection control
      • Staff safety
      • Virus
      • Pandemic
      • Investigation
      • Legal issue
      • Regulatory issue

    By SafeDavid3, 24 February, 2022

    • 0 comments
    • 780 views
    • 
    • Added by SafeDavid3
    • 24 February, 2022

15. Special Health Authority for Independent Maternity Investigations: Statement from Sajid Javid (26 January 2022)

    • Investigation
    • Maternity
    • (and 6 more)

      Tagged with:

      • Investigation
      • Maternity
      • Patient safety incident
      • Patient safety strategy
      • Collaboration
      • Patient / family involvement
      • Organisational learning
      • Patient harmed

    By Patient Safety Learning, 26 January, 2022

    • 0 comments
    • 1,658 views
    • 
    • Added by Patient Safety Learning
    • 26 January, 2022

16. Learning from incidents in healthcare: the journey, not the arrival, matters (1 April 2016)

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

      Tagged with:

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

    By Becky T, 29 September, 2021

    • 1 comment
    • 1,779 views
    • 
    • Comment by richard vA
    • 14 December, 2021

17. Why error reporting systems should be voluntary (2000)

    • Human error
    • Reporting
    • (and 3 more)

      Tagged with:

      • Human error
      • Reporting
      • Doctor
      • Safety culture
      • Policies / Protocols / Procedures

    By Becky T, 26 September, 2021

    • 0 comments
    • 967 views
    • 
    • Added by Becky T
    • 26 September, 2021

18. Nursing Matters podcast: Patient safety – Learning from our mistakes (24 September 2021)

    • Patient safety incident
    • Organisational learning
    • (and 2 more)

      Tagged with:

      • Patient safety incident
      • Organisational learning
      • Nurse
      • Data

    By Patient Safety Learning, 24 September, 2021

    • 0 comments
    • 1,607 views
    • 
    • Added by Patient Safety Learning
    • 24 September, 2021

19. Confidential enquiry into the deaths of Asian and Asian British babies: joint letter to Nadine Dorries, MP (6 September 2021)

    • Investigation
    • Maternity
    • (and 5 more)

      Tagged with:

      • Investigation
      • Maternity
      • BAME
      • Baby
      • Patient death
      • Health inequalities
      • Health Disparities

    By Patient Safety Learning, 10 September, 2021

    • 0 comments
    • 1,288 views
    • 
    • Added by Patient Safety Learning
    • 10 September, 2021

20. Robbie Powell: Time for Truth, Justice and Accountability (Sharon Hartles, August 2021)

    • Patient death
    • Duty of Candour
    • (and 2 more)

      Tagged with:

      • Patient death
      • Duty of Candour
      • Accountability
      • Transparency

    By Mark Hughes, 17 August, 2021

    • 1 comment
    • 17,008 views
    • 
    • Comment by Steve Turner
    • 2 September, 2021

21. Action Against Medical Accidents (AvMA): What you need to know about AvMA

    • Patient
    • Patient harmed
    • (and 4 more)

      Tagged with:

      • Patient
      • Patient harmed
      • Complaint
      • Investigation
      • Legal issue
      • Patient / family involvement

    By Mark Hughes, 15 July, 2021

    • 0 comments
    • 1,070 views
    • 
    • Added by Mark Hughes
    • 15 July, 2021

22. Causes and conditions in patient safety

    • Investigation
    • Just Culture

    By PatientSafetyLearning Team, 18 June, 2021

    • 0 comments
    • 1,097 views
    • 
    • Added by PatientSafetyLearning Team
    • 18 June, 2021

23. Once for Wales Concerns Management System

    • Patient safety incident
    • Quality improvement
    • (and 5 more)

      Tagged with:

      • Patient safety incident
      • Quality improvement
      • Complaint
      • Digital health
      • Legal issue
      • Risk management
      • Reporting

    By Patient Safety Learning, 20 April, 2021

    • 0 comments
    • 1,685 views
    • 
    • Added by Patient Safety Learning
    • 20 April, 2021

24. First Global Patient Safety Network Webinar 2021 - Patient safety incident reporting and learning systems (5 March 2021)

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

      Tagged with:

      • Patient safety incident
      • Reporting
      • Organisational learning
      • Quality improvement

    By Patient Safety Learning, 15 April, 2021

    • 0 comments
    • 1,021 views
    • 
    • Added by Patient Safety Learning
    • 15 April, 2021

25. English and Welsh Ombudsman set out the case for '... a proper public inquiry into the tragic death of Robbie Powell'

    • Police
    • Post mortem
    • (and 15 more)

      Tagged with:

      • Police
      • Post mortem
      • Harmed Care Pathway
      • Medicine - Diabetes and Endocrinology
      • Patient death
      • Competence
      • Criminal behaviour
      • System safety
      • Leadership
      • Organisational culture
      • Organisational learning
      • Whistleblowing
      • Transparency
      • Patient engagement
      • Children and Young People
      • Investigation
      • Coroner reports

    By Steve Turner, 17 November, 2020

    • 5 comments
    • 6,169 views
    • 
    • Comment by Patient Safety Learning
    • 7 December, 2021