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Keith Bates



15 Fair

Profile Information

  • First name
  • Last name
  • Country
    United Kingdom

About me

  • About me
    I am a patient safety investigations and learning specialist and seeking to improve my knowledge base
  • Organisation
    The Royal Wolverhampton NHS Trust
  • Role
    Investigations & Learning Specialist

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  1. Community Post
    I think we can spend too much time determining e.g. what is a near miss, close call etc. There are many differing definitions one may be that an existing safety procedure was not followed, another that some intervention of one kind or another prevented an error from occurring, or an event that didn't harm anyone but could have and so on. We should concentrate on "Anything that may be a risk to safety" either in terms of identifying an issue through everyday work where we may be able to make some improvement or something that causes a risk or poor outcome to a patient and requires a deeper enquiry. I cant see much value in near miss per se as a term. Keith
  2. Community Post
    As discussed at the network meeting as I can find the relevant folder, this is my simplified approach to SEIPS and open to suggested changes. It's nothing new per se (interactions), just the way I am approaching it at the moment which, as the new world order (PSIRF) moves into play I am trying to test it out in a meaningful way. I have included a simplified example. Regards Keith Understanding System Interactions.pdf
  3. Community Post
    As discussed at the recent forum meeting, I have attached example slides of how HSIB bring SEIPS into the investigation framework taken from their recent 2022 conference. There is not a lot of narrative, but I hope you get the gist. I will post an example of how I have blended SEIPS into investigations and also thematic analysis shortly. Regards arterial line example HSIB.pdfKeith
  4. Community Post
    If you have not already done so and you are involved with investigating patient safety incidents, I would encourage anyone to sign up for the courses run by HSIB Investigation education | HSIB The education programme is based on investigation science, which is a combination of elements from: safety science investigation process investigation skills investigation strategy and leadership As we will move away from root cause, as there is no root cause in a complex system, understanding systems investigation will be more beneficial. Regards Keith
  5. Community Post
    Interesting report by the Parliamentary & Health Service Ombudsman on imaging as a patient safety issue. Published evidence from PHSO case findings. The report shows recurrent failings in the way X-rays and scans are reported on and followed up across NHS services. Keith Unlocking_Solutions_in_Imaging_working_together_to_learn_from_failings_in_the_NHS - EMBARGO.pdf
  6. Community Post
    Hi Gethin Digital Healthcare is a bit broad and I will just refer to it as the "product". You could consider 1. Collection – search and obtain digital evidence and acquisition of data, consider use of audit logs to confirm actions of humans and systems and their behaviours. 2. Examination - applying techniques to identify and extract data this may require manufacturer reports or expert evidence of hardware/software. 3 Analysis – using data and resources to support case findings. 4. How this relates to other information gathered e.g. normal investigation methodology. 5. Reporting – presenting the info gathered (e.g., written case report) also consider areas such as e.g.: 1. Human reliability and error (one off or repetitive) interacting with the product 2. Behaviours and attitudes e.g. human and product interaction 3. Have human factors been built into systems engineering, effects of human factors and cognitive behaviour during interaction 4. How the product was designed tested if bespoke and in house (external reporting from private companies) 5. Method of input/output and the operations that form the process 6. How the product fits into the safety culture 7. Look at human centred design e.g. through the life cycle 8. User experience It may be difficult to build a one size fits all, perhaps some broad strokes e.g. first para and then focus points on the product involved, e.g. IPad and software used for community nursing on home visits. Hope this of some help and happy to advise where I can Regards Keith
  7. Community Post
    Earlier I wrote a short piece in relation to investigations, motivations and behaviours that lead to error. Pending the future PSII syllabus I have since adopted a model that enabled me to obtain a wider understanding of cognition and how the journey of decision making is affected by different levels of bias within that journey. The effect of behaviours and system safety will be a key driver, often bias is referenced just as an end point, but like most decision making journeys there is more often than not a beginning, a middle and an end, the failure point (the root cause). Using this model I have been able to identify that within 100% of diagnostic errors over a period of time these cognitive behaviours are present on "each and every occasion", within that there is also a high incidence of communication failure, which you can also associate in the main to those cognitive behaviours. That poses the question in terms of patient safety how do you improve cognitive behaviour? Changing policy, pathway, procedure will not remove cognitive error alone? Diagnosis is made by some interacting combinations of intuitive automatic processing [Kahneman system 1 thinking] and deliberate rational consideration [system 2 thinking]. The majority of clinical diagnosis are derived intuitively by acknowledging that most conditions are common and easily identified. These judgments cannot be taught they emerge subconsciously but intuition can be strengthened and improved. Bias affects decision making and the model adopted is now being built into the investigative doctrine to enable the identification of bias within patient safety incidents but importantly the journey of decision making will be able to be identified as part of the wider "system" to improve patient safety and being undertaken by: Shared learning template to communicate the behaviour influences, a review of the patient communication approaches, developing a post incident review into "reflection" to mirror the identification of the cognitive errors within the incident, short term post incident e-learning and longer term educational approaches to cognition and metacognition. This approach is to promote warnings about possible bias, show how bias distorts good decision making and at what point, when an individual has made a bias related judgement error providing effective feedback, repeating extended coaching. This is an important area for consideration and happy to receive information on any other approaches. Keith
  8. Community Post
    This short summary is very much about understanding behaviours and motivations within a safety investigation framework. Daniel Kahneman pioneered the science of behavioural economics and received the Nobel Prize for his work, he developed the concept of “Dual Process Theory” and how humans think fast and slow and how human thinking is affected by heuristics and cognition. It’s about how humans think and make judgements. He identified that there were a wide range of cognitive/thinking biases, cognitive error refers to any errors (SRK) at any level in the hierarchy of thinking processes. Kahneman & Tversky identified that these were particularly common in medical incidents with clinical error at the centre of those incidents. When humans think about a problem and a solution, we use heuristic logic, a short cut system. Our brains have evolved to make rapid decisions, a best guess often without considering all the facts before us. It is vital for making quick and sometimes lifesaving decisions. The problem is that clinical decisions often need a more considered approach, this can over time become habitual and leads to errors. I don’t want to get too heavy on the theories here, there is plenty of information available on the net and also of interest is Dr Pat Croskerry, Dalhousie University who has identified 50 cognitive biases in healthcare. Humans are part of the sociotechnical system, humans, machines and the organisation operating together. In healthcare it includes people, interactions and relationships as part of a larger thing, operating collectively towards a common purpose. Safety is a control problem, or can be viewed as such and safety is managed by a control structure. Investigators therefore should be able to identify why the existing control structure failed, or which parts of it failed. To prevent future error requires a control structure that can be designed that will enforce the necessary constraints on the system to ensure safe operation and can continue as such as changes occur. What then of human error within the sociotechnical system, how do we understand it. Often it is discoverable evidence of the adverse event which leads to a finding of e.g. human error, but what we don’t seem to analyse so well is people’s intentions and behaviours which, do not come about from factual evidence per se, e.g. what motivated our decision or behaviour. How do we understand this in the context of the investigation, identifying this can be extremely challenging, identifying what motivated how we perceived a situation? However, this can lead to a richer understanding of the influences on human behaviour. I have been looking at models that can be inserted into a core investigative doctrine for safety and to date I have settled on that posed by Dr Russell Kelsey MB.BS.MRCGP a subject matter expert in serious clinical investigation which places clinical error at the centre of three influences of attitude, attention and cognition and the effects of various biases within those three influences and situational awareness and high pressure environments. I am not connected to Russell and also do not want to be seen as breaching any copyright within this but more information can be found in his book at https://www.amazon.co.uk/Patient-Safety-Investigating-Reporting-Incidents/dp/1498781160 which I have found very informative. Has anyone developed a method/model that looks deeper at the context behind human error as I would be interested in the approach. The new PSIRF will transform our approach refocusing on systems, processes and behaviours and whilst early adopters are trialling the framework it does not stifle discussion and consideration for improvements and would be interested of any developments already within investigation management . Many thanks Keith Investigations & Learning Specialist- RWHT
  9. Community Post
    https://improvement.nhs.uk/home/ For information published today
  10. Community Post
    Thanks this is interesting having worked with restorative justice practioners I am (subject to budgets!) looking to adopt this into the learning environment so a useful debate subject Keith
  11. Community Post
    Hi, Sorry meant to attach this scoping document have converted to pdf and hope it is of some use. RCA in this method is just an analytical tool and we are moving away from the term root cause Overview Patient Safety Investigations.pdfOverview Patient Safety Investigations.pdf
  12. Community Post
    If the trust owns the data e.g. records, statements from staff etc it is usually not an issue, the questions is raised when a patient/family may have their own material e.g. video/audio/photograps on smartphones or other correspondence such as letters or emails etc. Personaly I would always ensure I have written consent from them to use it. This could be recorded in for example their witness statement saying that they consent to abc using the material for the purposes of the investigation, and what will happen to the material once the investigation is concluded. I would not want want for example an aggrieved party who is not later happy with the investigation outcome to then be using a complaint to the information commissioners on the issue of consent or the retention of data (post) and written is provable where verbal may be a contentious point. All information is subject to GDPR. Section from Recital 42 GDPR " Where processing is based on the data subject’s consent, the controller should be able to demonstrate that the data subject has given consent to the processing operation. In particular in the context of a written declaration on another matter, safeguards should ensure that the data subject is aware of the fact that and the extent to which consent is given"
  13. Community Post
    Hi all I don't think the documents and the detail will be ready until next year buut I have modelled out an approach taken from my own background and researching a number of sources and unapoligetic for plagerising some ideas also. This short pdf is about my designing of a process that can be adaptive to change and develop some consistency across our trust in due course. I would of course appreciate alternative views, constructive comments and ideas, as I say it lacks areas of detail which I can elaborate on if required as I say just an outline. KeithPatient Safety Investigations Model design.pdf
  14. Community Post
    I have currently designed an investigation method and a training model which is under consideration with the trust a step/method approach, as soon as it has been agreed I will happily post. It has moved away from RCA per se, but still retaining it as an analytical tool within alongside other approaches. The method looks at investigative foundations, investigative methodology, witness interviewing, support tools and methods of analysis, hierarchy of learning and recomendations, supporting families, staff and establishing what is need for systems change. I am trying to make it a more flexible investigative approach that can respond to incident at hand. As aluded to above I agree from my time here there are repeated themes/events/learning and beyond this method I want to look at systems contsraints that enforce the necessary behaviour changes e.g. People, Systems and Tasks Keith Investigations & Learning Specialist Royal Wolverhampton Trust