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Event
HSIB Safety Investigations Conference 2023
Patient Safety Learning posted an event in Community Calendar
The annual Healthcare Safety Investigation Branch (HSIB) conference agenda will cover: A focus on patient and family engagement. Sharing learning from HSIB national investigations – what has been learnt and how it can help support and improve local investigation practice. HSIB's maternity investigation programme work with families and trusts. This includes how HSIB implements learning from investigations and where the opportunities are to influence change. HSIB's work on Safety Management Systems. How HSIB's education programme is sharing learning to develop and improve local safety investigations. • An overview of HSIB's international work. Breakout sessions to share knowledge. You will also hear how the HSIB will form into the Health Services Safety Investigations Body and the Maternity and Newborn Safety Investigations (MNSI) function and how this may impact you. Register -
Event
Root Cause Analysis: 1 day masterclass
Patient Safety Learning posted an event in Community Calendar
This intensive masterclass will provide in-house Root Cause Analysis training in line with The NHS Patient Safety Strategy (July 2019). The course will offer a practical guide to Root Cause Analysis with a focus on systems-based patient safety investigation as proposed by the forthcoming National Patient Safety Incident Response Framework which emphasises the requirement for investigations to be led by those with safety investigation training/expertise and with dedicated time and resource to complete the work. This course will include an opportunity for learners to gain a Level 3 qualification (A level equivalent) in RCA skills (2 credits / 20 hours) on successful completion of a short-written assignment. This one-day course is designed to provide delegates with the key skills and knowledge that they will require to conduct Root Cause Analysis effectively. The course content walks learners through the seven-key stages to conducting a high-quality Root Cause Analysis investigation. We pay particular attention to planning and managing investigations, interviewing staff, mapping information, using appropriate analysis tools to establish contributory factors, plus focus on creating fit-for-purpose action plans and final reports. We advocate Root Cause Analysis as a teambased approach and concur with NHS Improvement’s 2018 statement ‘investigations must be led by trained investigators with the support of an appropriately resourced investigation team’. The course is facilitated by Tracy Ruthven and Stephen Ashmore who have significant experience of undertaking patient safety reviews in healthcare. They were commissioned to write a national RCA guide by the Healthcare Quality Improvement Partnership. Register -
Event
Investigation and learning from deaths
Patient Safety Learning posted an event in Community Calendar
This National Conference focuses on improving the investigation and learning from deaths in NHS Trusts. By collecting the data and taking action in response to failings in care, trusts will be able to give an open and honest account of the circumstances leading to a death. There will be an extended focus on engaging and involving patients, families and staff following a death, and on learning from deaths including an update from a coroner. From April 2023, all deaths in the community or acute settings that do not require to be referred to the coroner (non-coronial deaths) will be scrutinised by a medical examiner. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/investigation-learning-deaths-hospital-mortality or email frida@hc-uk.org.uk. hub members receive a 20% discount code. Email info@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #LFDNHS -
EventThe Patient Safety Incident Response Framework (PSIRF) was published on 16th August 2022 and replaces the Serious incident Framework. This national conference looks at the practicalities of Serious Incident Investigation on and Learning and how this has changed with the publication of PSIRF. The conference will also update delegates on best practice in serious incident investigation under PSIRF and ensuring the focus is on learning from improvement. There will also be a extended focus on learning, including mortality governance and learning from deaths ensuring insight and investigation findings lead to improvement. The conference will include updates from PSIRF early adopter sites. The conference update delegates on the new Patient Safety Incident Response Standards and how to review your current practice against these standards. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/serious-incident-investigation-patient-safety or email kate@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #NHSSeriousIncidents
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Event
HSIB: Demystifying thematic analysis
Patient Safety Learning posted an event in Community Calendar
This session will build on the concepts discussed within HSIB’s Level 2 in Safety Investigation programme and will provide an opportunity to ‘have a go’ and discuss some of the challenges and practical aspects of using thematic analysis for the purpose of learning from patient safety issues. Enrol -
EventuntilThe Patient Safety Incident Response Framework (PSIRF) sets out a new approach to learning and improving following patient safety incidents across the NHS in England. Compassionate engagement and involvement of those affected by patient safety incidents is central to the PSIRF approach. Building on our workshop that explored different models for engaging with families, this workshop will highlight how different organisations are approaching engaging with staff affected by patient safety incidents. PSIRF webinars are open to everyone to attend, including both NHS and arm’s length bodies Presenters: Tracey Herlihey, Head of Patient Safety Incident Response, NHS England Lauren Mosley, Head of Patient Safety Implementation, NHS England, Mrs Christina Rennie, Consultant Ophthalmologist, Clinical Director of Patient Safety and Patient Safety Specialist, University Hospital Southampton NHS Foundation Trust Register for this event Registration closes at 12noon Wednesday 19 April 2023. A link to join the webinar will be sent to registered delegates shortly after registration closes.
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EventThis national conference looks at the practicalities of serious incident investigation and learning from deaths in mental health services and implementation of the New Patient Safety Incident Response Framework (previously known as the Serious Incident Framework). The Patient Safety Incident Response Framework (PSIRF) was published on 16th August 2022 and replaces the Serious Incident Framework. The conference will also update delegates on best current practice in serious incident investigation and learning, including mortality governance and learning from deaths. There will be an extended focus on ensuring serious investigation findings lead to change and improvement, and updates from PSIRF early adopter sites in mental health. The conference will also examine how the new framework will fit with the Royal College of Psychiatrists Care Review Tool for mortality review. The conference is particularly timely considering the current Essex Mental Health Independent Inquiry which has National Implications. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/investigation-of-deaths-serious-incidents-in-mental-health-services or email: frida@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for discount code. Follow this conference on Twitter @HCUK_Clare #SIMental
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EventThis conference focuses on recognising and responding to the deteriorating patient and ensuring best practice in the use of NEWS2. The conference will include National Developments including the recommendations on NEWS2 and Covid-19, and implementing the recommendations from the Healthcare Safety Investigation Branch Report Investigation into recognising and responding to critically unwell patients. The day will include practical case study based sessions on identifying patients at risk of deterioration, improving practice in patient observations, the role of human factors in responding to the deteriorating patient, improving escalation and understanding success factors in escalation, sepsis and Covid-19, involving patients and families in recognising deterioration, using clinical judgement, and improving the communication and use of NEWS2 in the community, including care homes, and at the interface of care. The Recording of NEWS2 score, escalation time and response time for unplanned critical care admissions is now an NHS CQUIN goal. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/deteriorating-patient-summit or email kate@hc-uk.org.uk. hub members receive a 20% discount. Email: info@pslhub.org Follow on Twitter @HCUK_Clare #DeterioratingPatient
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EventThe Patient Safety Incident Response Framework (PSIRF) was published on 16th August 2022 and replaces the Serious incident Framework. This national conference looks at the practicalities of Serious Incident Investigation on and Learning and how this has changed with the publication of PSIRF. The conference will also update delegates on best practice in serious incident investigation under PSIRF and ensuring the focus is on learning from improvement. There will also be a extended focus on learning, including mortality governance and learning from deaths ensuring insight and investigation findings lead to improvement. The conference will include updates from PSIRF early adopter sites. The conference update delegates on the new Patient Safety Incident Response Standards and how to review your current practice against these standards. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/serious-incident-investigation-patient-safety or email kate@hc-uk.org.uk.. hub members receive a 20% discount. Please email info@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #NHSSeriousIncidents
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Learning from Never Events
Patient Safety Learning posted an event in Community Calendar
Never events are defined as “serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations.” They are designed to act as a red flag for improvement by NHS organisations. This one day masterclass will focus on safety culture around Never Events within healthcare organisations. There were 364 never events in 2020/21 and 349 between April 2021 and Jan 2022. The masterclass will look at how Never Events have been investigated and at Human Factors approaches to improving learning and the systems to reduce harm. It will compare our experiences with learning from serious incidents from other countries. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/learning-from-never-events or email kate@hc-uk.org.uk. hub members receive a 20% discount, Email info@pslhub.org for discount code. -
Event
Investigation and learning from deaths
Patient Safety Learning posted an event in Community Calendar
This National Conference focuses on improving the investigation and learning from deaths in NHS Trusts. By collecting the data and taking action in response to failings in care, trusts will be able to give an open and honest account of the circumstances leading to a death. There will be an extended focus on engaging and involving patients, families and staff following a death, and on learning from deaths including an update from a coroner. The conference will discuss the role of Medical Examiners in learning from deaths which is now being extended to all non-coronial deaths wherever they occur. The conference will also include a split stream where delegates can chose to focus on investigating and learning from either deaths in acute care, or deaths in primary and community care. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/investigation-learning-deaths-hospital-mortality or email aman@hc-uk.org.uk. With only a few places left, HCUK are offering hub members five discounted places at only £195+VAT with discount code HCUK195PSL. Follow the conference on Twitter @HCUK_Clare #LFDNHS -
Event
The future of healthcare investigations
Patient Safety Learning posted an event in Community Calendar
untilThis free webinar will explore what the future looks like for this critical area of human factors investigation. The presenters will each talk about a different aspect and there will be time for you to ask questions. The future of healthcare investigation: focus on learning and improvement Mark Sujan will talk about the new NHS England Patient Safety Incident Response Framework (PSIRF) which puts emphasis on learning and improvement. You’ll hear about the limitations of existing approaches to learning from incidents in healthcare, which PSIRF tries to overcome. You’ll then find out about the principles of organisational learning for achieving sustainable change, based on the CIEHF guidance. Transition: HSIB to HSSIB and MNSI HSIB’s Deinniol Owens will reveal that in April 2023, the Healthcare Safety Investigation Branch (HSIB) will transition into two new organisations: The Health Services Safety Investigation Body (HSSIB) and the Maternity and Newborn Safety Investigations (MNSI) Special Health Authority. You’ll get insight into the roles of the new organisations and hear about the additional focus on the new powers and opportunities available to HSSIB now that it’s been confirmed in statute by the Health and Care Act 2022. Investigation education: The transfer of knowledge Andrew Murphy-Pittock will explore one of the key objectives of HSIB, which is to transfer knowledge to those undertaking and overseeing patient safety investigations. You’ll find out how HSIB has developed a flexible, agile programme, working with colleagues at PSIRF, to help healthcare organisations on the move away from the Serious Incident Framework to a systems-focused approach to learning, involving those affected by incidents in the process. You’ll also hear about current and future plans for the education programme. Who will this be of interest to? This webinar should be of interest to healthcare professionals, investigators, change managers, process designers and anyone with an interest in patient safety. Register -
Event
Priorities for improving care and support for pregnant women
Sam posted an event in Community Calendar
This Westminster Health Policy forum conference will discuss the next steps for improving care and support for pregnant women. Delegates will assess priorities for the safety and quality of maternity services moving forward following the release of the Final Ockenden review: Independent Review of Maternity Services, and for the Maternity and Newborn Safety Investigation Special Health Authority (MNSI) division of the Healthcare Safety Investigation Branch being established for April 2023. It will be an opportunity to assess priorities for the Secretary of State, and to examine the future outlook for supporting pregnant women following the publication of the Women’s Health Strategy for England, which highlighted a need for pregnant women to be listened to - and included the ambition for 4m people to receive personalised care by March 2024. Areas for discussion include: personalised care: assessment of individual needs - improving the access to mental health services - promoting healthy lifestyle choices during pre-conception, pregnancy, and early years workforce support: encouraging professional development, including funding and education - maternal workforce recruitment and retention - improving senior leadership improving patient safety ensuring strong communication in maternity teams providing appropriate pregnancy risk assessment recommendations and guidance for clinical decision making encouraging and delivering continuity of care progress and next steps for the Maternity Transformation Programme following the Better Births report investigation: priorities for the MNSI and ensuring safety concerns are investigated and addressed - learning from mistakes - listening to families quality of care: developing best practice guidelines - delivering high quality services - improving pregnancy outcomes - improving communication with pregnant women inequalities: addressing variation in service provision - tackling disparities in pregnancy outcomes, particularly for ethnic minorities. Register -
EventFrontline staff often perceive event reporting as a black hole where no information exits once it enters. Join Andy Moyer, BSN, RN-BC, patient safety informatics specialist at Penn State Health Milton S. Hershey Medical Center, where he will help you tackle this perception by providing reporters better feedback. Moyer will also demonstrate ways to increase the quantity and quality of reported events. Register
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EventThis national conference looks at the practicalities of serious incident investigation and learning. The event will look at the development and implementation of the new Patient Safety Incident Response Framework (previously known as the Serious Incident Framework) a version of which has now been published. Local systems and organisations outside of the early adopter areas are free to use the already published version of the PSIRF to start to plan and prepare for PSIRF’s full introduction. The conference will also update delegates on best current practice in serious incident investigation and learning, including mortality governance and learning from deaths. There will be an extended focus on ensuring serious investigation findings lead to change and improvement, and updates from PSIRF early adopter sites. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/serious-incident-investigation-patient-safety or email nicki@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for a discount code. Follow on Twitter @HCUK_Clare #NHSSeriousIncidents
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EventThis national conference looks at the practicalities of serious incident investigation and learning from deaths in mental health services. The event will look at the development and implementation of the New Patient Safety Incident Response Framework (previously known as the Serious Incident Framework) which was published on 16 August 2022. The conference will also update delegates on best current practice in serious incident investigation and learning, including mortality governance and learning from deaths. There will be an extended focus on ensuring serious investigation findings lead to change and improvement, and updates from PSIRF early adopter sites in mental health. The conference will also examine how the new framework will fit with the Royal College of Psychiatrists Care Review Tool for mortality review. Register
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EventThis one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace and is aligned with the new Patient Safety Syllabus 2021. The new Patient Safety Strategy advises that organisations must adopt a new and broader approach to stimulate learning from patient safety incidents. This course is designed to assist healthcare professionals involved in this important work. The main purpose is to provide learners with a full understanding of the various approaches that can now be used to conduct patient safety incident investigation (PSIIs). Traditionally, root cause analysis has been used as a blanket approach to diagnosing why patient safety have been compromised, but healthcare teams are henceforth being encouraged to adopt a wider range of methods that will both save time and facilitate enhanced learning. The focus is now on appropriate proportionality in response to incidents that occur in their organisation. Key learning objectives: Understand the new patient safety landscape. Understand the need for proportionality of investigation. Learn how to use a range of techniques for conducting PSIIs. Understand how to write an impactful improvement plan. Consider how your current approach to patient safety investigations compares to the agreed national standards. Understand typical pitfalls and traps associated with this wider workstream and tips for avoiding them. Register
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Human Factors in accident investigation
Patient Safety Learning posted an event in Community Calendar
untilThis free webinar will uncover the intricacies of accident investigation from a human factors perspective. It will feature examples from rail, air and maritime from our speakers who are all specialist human factors investigators. Hear first hand how they tackle investigations and get insights into this vital work that lead to improvements in safety across all travel sectors. Will Tutton will briefly mention the Herald of Free Enterprise, but will mainly talk about the cargo vessel Kaami, which ran aground in Scotland in March 2020. The investigation focused on front line operators. Lisa Fitzsimons will talk about common themes relating to human performance and organisational factors which emerge when investigating the technical aspects of an air accident, drawing upon several recent examples. Becky Charles will discuss track worker safety and specifically about an incident which occurred at Margam, UK in July 2019 where two trackworkers were struck and fatally injured. Register -
EventSEIPS 2.0 is the most widely used model in human factors in healthcare. This one day masterclass will look at the model itself and how it can be applied to healthcare departments. It will look at real world examples as well as the literature. SEIPS 2.0 is the next-generation healthcare human factors model , which embraces 3 principles of Systems orientation, Person-centeredness and Design-driven improvement. Key learning objectives What is SEIPS 2.0? How does SEIPS link to Patient Safety? How to use SEIPS 2.0 clinically? • How to improve technology? Engaging patients and families Register hub members receive a 20% discount. Email info@pslhub.org
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Event
Just Culture and incident investigation
Patient Safety Learning posted an event in Community Calendar
untilThis virtual seminar from the Clinical Human Factors Group will be looking at Just Culture and incident investigation and will feature two of the authors, Jan Davies and Carmella Steinke, of the new book 'Fatal Solution' , a book which describes "how a healthcare system used tragedy to transform itself and redefine Just Culture". In this provocative true story of tragedy, the authors recount the journey travelled and what was learned by, at the time, Canada’s largest fully integrated health region. They weave this story together with the theory about why things fall apart and how to put them back together again. Building on the writings and wisdom of James Reason and other experts, the book explores new ways of thinking about Just Culture, and what this would mean for patients and family members, in addition to healthcare providers. With afterwords by two of the major players in this story, the authors make a compelling case that Just Culture is as much about fairness and healing as it is about supporting a safety culture." To accompany this story Ken Catchpole, Professor of Human Factors at Medical University of South Carolina will discuss a variety of enablers and barriers to learning from clinical safety incidents, based on his perspective within the US health system. This will illustrate the format of incident analysis and response at MUSC; legal and regulatory issues; and the role and impact of human factors and systems engineering. He will also comment on the recent RaDonda Vaught case, and what that tells us about how far we still have to go. Jane O’Hara, Professor of Healthcare Quality and Safety in Leeds will adds a UK perspective to this worldwide issue, together with a session focusing on the view from a pharmacy perspective. Register- Posted
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EventuntilThis two day masterclass will start by providing learners with a full understanding of the various approaches that can now be used to conduct patient safety incident investigation (PSIIs) followed by how to use Human Factors in your workplace. All medical and non-medical staff should attend. For further information and to book your place visit www.healthcareconferencesuk.co.uk/virtual-online-courses/human-factors-safety-investigations or email kerry@hc-uk.org.uk hub members receive 20% discount. Email info@pslhub.org for discount code.
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Healthcare Safety Investigations Conference 2022
Sam posted an event in Community Calendar
untilThe Healthcare Safety Investigation Branch (HSIB) conference is for all healthcare staff and in particular those interested in patient safety and who conduct investigations. The conference will provide: a focus on our maternity, national and investigation education programmes, an opportunity to share learning to help make patient care safer in your organisation, expertise on conducting professional healthcare safety investigations in your setting, updates on the future of our national and maternity programmes, as they form into either the Health Services Safety Investigations Body (HSSIB) or the new maternity Special Health Authority. What can you expect on the day? The full agenda is now available. Hear from Dr Rosie Benneyworth, the new Interim Chief Investigator and have the chance to ask her questions. Find out more about how HSIB drives systems level change through our national investigations. Get insight into how our maternity investigation programme is making a difference in maternity care. Hear from the Norwegian Healthcare Investigation Board (Ukom), detailing their experiences of becoming a national health investigation body. There is also a programme of breakout sessions, led by our investigation education team, which cover everything from investigative interviewing to using thematic analysis in healthcare investigations. Register -
EventThis national conference looks at the practicalities of Serious Incident Investigation and Learning. The event will look at the development and implementation of the new Patient Safety Incident Response Framework (previously known as the Serious Incident Framework) a version of which has now been published and which is being tested in early adopter sites. NHS Improvement is working with these early adopters to test implementation, and analysis of this will inform the final version with the revised framework due in Summer 2022. Local systems and organisations outside of the early adopter areas are free to use the already published version of the PSIRF to start to plan and prepare for PSIRF’s full introduction. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/serious-incident-investigation-patient-safety or email kate@hc-uk.org.uk hub members receive 20% discount. Email info@pslhub.org for discount code Follow on Twitter @HCUK_Clare #NHSSeriousIncidents
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EventuntilThe Patient Safety Incident Response Framework (PSIRF) will be published early August 2022, as a major piece of guidance on how NHS organisations respond to patient safety incidents, and ensure compassionate engagement with those affected. Secondary care providers will be asked to begin preparing to transition to PSIRF from September 2022. Preparation is expected to take 12 months with all organisations transitioning to PSIRF by August 2023. This webinar will be hosted on MS Teams Live to provide: An introduction to the Patient Safety Incident Response Framework and accompanying guidance An overview of the next steps for providers as they begin work to prepare to transition to the framework An outline of the six preparation phases over the next 12 months Details of resources and support to help providers prepare for PSIRF Opportunities to ask questions. Presenters: Tracey Herlihey, Head of Patient Safety Incident Response Policy, NHS England National Patient Safety Team Lauren Mosley, Head of Patient Safety Implementation, NHS England National Patient Safety Team Register
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EventThis conference focuses on investigating and learning from deaths in the community/primary care. The conference focuses on the extension of the Medical Examiner role to cover deaths occurring in the community and the role of the GP in working with the Medical Examiner to learn from deaths and to identify constructive learning to improve care for patients. The conference will also focus on implementation of the new Patient Safety Incident Response Framework and learning from a primary care early adopter. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/investigation-of-deaths-community or email nicki@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #LearningfromdeathsPC
