Jump to content
  • Content Count

    17
  • Joined

  • Last visited

Keith Bates

Members

Everything posted by Keith Bates

  1. 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
  2. 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
  3. 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
  4. 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
  5. Content Article Comment
    Accident_Analysis_Models_and_Methods_Gui.pdf 2013 but free read Accident_Analysis_Models_and_Methods_Gui.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 – pr
  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 mo
  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.
  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 ex
  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 Inves
  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
×