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Showing results for tags 'Investigation'.
Found 1,566 results
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Content ArticleIn this episode of the Institute of Economic Affairs (IEA) Podcast, IEA Head of Political Economy Dr Kristian Niemietz discusses the findings of the Independent Medicines and Medical Devices Safety Review, and how the healthcare system in England responds to reports about harmful side effects from medicines and medical devices. Kristian speaks with Simon Whale, panel member and communications lead for the Independent Medicines and Medical Devices Safety Review and Dr Sonia Macleod, lead researcher, Independent Medicines and Medical Devices Safety Review. They discuss how the NHS, and other health bodies, could improve their services to address poor care and prevent harm.
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Content ArticleCoroner regulations: Regulation 28 - Report on action to prevent other deaths. Regulation 29 - Response to a report on action to prevent other deaths.
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Content ArticleRule 43 reports were replaced on implementation of the Coroners and Justice Act 2009 with Reports on Action to Prevent Future Deaths (‘reports’) .For short they can be referred to as PFDs or PFD reports or Regulation 28 reports. These reports are important. Coroners have a duty not just to decide how somebody came by their death but also, where appropriate, to report about that death with a view to preventing future deaths. A bereaved family wants to be able to say: ‘His death was tragic and terrible, but at least it shouldn’t happen to somebody else.’ Broadly speaking reports should be intended to improve public health, welfare and safety. They should not be unduly general in their content; sweeping generalisations should be avoided. They should be clear, brief, focused
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Content ArticlePresentation from Patricia Harding, Senior Coroner, Mid Kent & Medway, North East Kent, Central & South East Kent on the role of the coroner. Includes reportable deaths, the Cor0navirus Act 2020, how to complete a MCCD, inquests, preparation of reports and giving evidence.
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Content ArticlePodcast from the NHS England and NHS Improvement National Patient Safety Team, where Tracey Herlihey, head of patient safety incident response policy, and Lauren Mosley, head of patient safety implementation, talk about the Patient Safety Incident Response Framework (PSIRF) which will be launched in Spring 2022. The framework is a key component of the NHS Patient Safety Strategy, and will outline how NHS providers should respond to patient safety incidents and how and when a patient safety investigation should be conducted. Once implementation is completed it will replace the current Serious Incident Framework. The podcast gives an overview of PSIRF and its key features, talks about findings from work with early adopters over the past two years to pilot an introductory version of the framework, and explains what providers can do now to prepare for its launch in the Spring.
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Content ArticleThe West Suffolk Review, commissioned by NHS England on behalf of the Department for Health and Social Care, was published last month. NHSE/I asked the West Suffolk Board to produce an action plan for the 28 January meeting of the Board of Directors. This paper summarises the current position in relation to the learning, reflection and response thus far, including the organisational development actions that have already been taken and require further embedding. It also highlights the engagement undertaken to date, and what more needs to happen, to ensure our plans are based on the priorities for staff, governors, patients and teams and can carry the confidence of stakeholders. The report, 'West Suffolk Review – organisational development plan (p. 217)', sets out nine broad themes of work, linked to the trust’s core functions, “that capture the priority areas for organisational and cultural development at WSFT in light of the learnings from the report”. The document sets out how the trust’s governance, freedom to speak up, HR, staff voice, patient safety and other parts of its corporate infrastructure failed and contributed to a scandal.
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Content ArticleThe COVID-19 pandemic placed unprecedented pressure on councils and care providers. A new report from the Local Government and Social Care Ombudsman analyses just how those organisations coped.
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Content ArticleA letter to the Chair of the Commons Health and Social Care Select Committee expressing concern that written evidence provided to the Committee's “Coronavirus: Lessons Learned to Date" inquiry was not properly considered and opportunities to protect healthcare workers from disease were missed.
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Content ArticleEvidence submitted outlining the issues relating to the protection of health and care workers. It explains how surgical masks are not 'protective' against airborne disease and represent a breach of COSHH Regulations.
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Content ArticleWith allegations into racial discrimination at the workplace rarely upheld by employers or courts, Roger Kline, Naledi Kline and Joy Warmington give a set of questions for investigators to ensure more robust investigations.
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HSIB Maternity newsletter (May 2021)
Patient Safety Learning posted an article in HSSIB investigations
HSIB is pleased to present the first quarterly newsletter sharing learning from trusts across the whole of England. The purpose of this newsletter is to allow clinical teams and trusts to share the changes that have been made as a result of the findings and recommendations from maternity investigations undertaken by the Healthcare Safety Investigation Branch (HSIB). These initiatives were developed by the trusts and their maternity teams, we would like to thank them for sharing their work with others. This approach to collaborative learning supports trusts to share resources and improvement ideas that relate to similar concerns each trust experiences, as they strive to continually improve the care and safety of mothers and their babies. These examples of learning reflect what is being implemented in trusts with varying requirements to support their maternity services. This allows what is learnt in Newcastle to be known about in Penzance. -
Content ArticleWhere a new or under-recognised risk identified through the NHS England's review of patient safety events doesn’t meet the criteria for a National Patient Safety Alert, NHS England look to work with partner organisations, who may be better placed to take action to address the issue. To highlight this work and show the importance of recording patient safety events, they publish regular case studies. These case studies show the direct action taken in response to patient safety events recorded by organisations, staff and the public, and how their actions support the NHS to protect patients from harm.
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Content ArticleThis dissertation from Ivan Pupulidy, Tilburg University, introduces a network of practices that transformed the United States Department of Agriculture (USDA) Forest Service accident investigation. This dissertation uses case studies to show the interweaving of organisational and individual journeys, each of which began with the strength to inquire and to challenge assumptions. The case studies show how constructed realities, including my own, were challenged through inquiry and how four practices emerged that supported sense making at both the field and organisational leadership levels of the organisation.
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Content ArticleThis report by the Healthcare Safety Investigation Branch (HSIB) has been published as part of a local pilot, which has been launched to evaluate HSIB’s ability to carry out effective investigations occurring between specific hospitals and trusts. After an evaluation, it will be decided whether this model can be implemented more widely by HSIB. This investigation reviewed the case of a woman who was taken to an emergency department by ambulance in April 2021, following a 999 call from her Granddaughter to the emergency operations centre. The emergency operations centre used the wrong NHS number for the patient, which was assigned to her for the duration of her stay in hospital and led to her being offered incorrect medication.
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Content ArticleIn this blog Patient Safety Learning provides an overview of the key points included in its response to the call for evidence for the Health and Social Care Select Committee Inquiry examining the case for reform of NHS litigation.
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Content ArticleTwo years ago, a patient safety incident at North Bristol Trust led to the introduction of Swarm – a step change in how the trust responds to safety incidents. Swarm is a form of safety incident huddle that takes place as close as possible in time and place to the incident, allows blame-free investigation and leads to prompt action. This article describes how Swarm works, its advantages over root cause analysis, and how it is being embedded in the safety culture of North Bristol Trust.
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Content ArticleThe purpose of this investigation by the Healthcare Safety Investigation Branch (HSIB) is to help improve patient safety in relation to the management of patients with COVID-19 being treated with non-invasive respiratory support, for example continuous positive airway pressure (CPAP), in non-critical care settings. The HSIB investigation reviewed the experience of Terry, who was admitted to hospital with symptoms of COVID-19 and required support with is breathing using CPAP. On the second day after his admission to hospital, Terry was found on the floor next to his bed, having called for assistance. Terry’s CPAP tubing had become disconnected from his mask, meaning that Terry’s breathing was not supported. Staff attempted to resuscitate Terry, however they were unsuccessful, and he died.
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Content ArticleThis report was triggered by the Coroner’s report into the death of Evan Nathan Smith in North Middlesex hospital. Evan was a young man with his whole life in front of him. The mistakes made in his treatment leading to his early and avoidable death brought into sharp focus the lack of understanding of sickle cell, the battles patients have to go through to get proper treatment and the terrible consequences which can come about as a result. Following the publication of the Coroner’s report, the All-Party Parliamentary Group (APPG) on Sickle Cell and Thalassaemia held three evidence sessions, hearing from patients, clinicians and politicians. This report is a result of that evidence. The findings in this report reveal a pattern of many years of sub-standard care, stigmatisation and lack of prioritisation which have resulted in sickle cell patients losing trust in the healthcare system that is there to help them, feeling scared to access hospitals, expecting poor treatment from some of those who are supposed to care for them and fearing that it is only a matter of time until they encounter serious care failings.
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Thought piece on the Ockenden Report by Susan Stanford
Patient Safety Learning posted an article in Maternity
People with an interest in patient safety read the interim Ockenden report with despair. It was immediately and starkly apparent that it repeated many of the common themes which have emerged in other patient safety investigations. Many of the recommendations in the Ockenden report were already covered by national guidance, Susan Stanford asks why the guidance wasn’t followed and whether it might not be being followed elsewhere. -
Content ArticlePatient safety incidents (PSIs) are common and can lead to fatal outcomes. Effective investigation of PSIs is essential to optimise learning and take action to prevent further incidents occurring. The Yorkshire Contributory Factors Framework is a tool which has an evidence base for optimising learning and addressing causes of patient safety incidents by helping clinicians, risk managers and patient safety officers identify contributory factors of PSIs. Incidents that occur in a hospital setting have been well studied and all contributory factors have been mapped. Based on this research, a team of practicing clinicians with human factors experts has adapted the evidence to a pragmatic 2 page framework. The document suggests questions that you might want to ask of those involved in the incident. The underlying aim of this tool is not to ignore individual accountability for unsafe care, but to try to develop a more sophisticated understanding of the factors that cause incidents.
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Diagnostic Errors: Technical Series on Safer Primary Care (2016)
Patient-Safety-Learning posted an article in WHO
This document from the World Health Organization raises awareness about strategies that could reduce diagnostic errors in primary care. It highlights the importance of examining diagnostic errors, identifies the most common types of diagnostic error in primary care and describes potential solutions. -
Content ArticleThis session at HSIB's second annual Patient Safety Investigation Conference explored the national investigation process from referral of incidents to the publication of the report. The session will also provided detail of how we involve patients, families and service users during the investigation process. Download the session View the video
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Transvaginal mesh timeline (7 December 2017)
Patient-Safety-Learning posted an article in Women's health
This blog sets out a timeline of the major landmarks for transvaginal surgical mesh since its first approval in 1996. -
Content ArticleA new report from two House of Commons committees highlights the UK’s failed pandemic response. Martin McKee, professor of European Public Health, London School of Hygiene & Tropical Medicine, unpicks the findings.
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Content ArticleThese tools and worksheets have been produced by NHS England to assist staff in conducting patient safety incident investigations. NHS England stresses that patient safety investigation is an important and complex task and should only be undertaken by those who have attended training and gained skills and experience from specialists in the field.
