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Showing results for tags 'Investigation'.
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Content ArticleOn 22 September 2021 the Health and Social Care Select Committee launched a new inquiry examining the case for reform of NHS litigation, identifying concerns regarding a significant increase in clinical negligence costs and missed opportunities for learning to improve patient safety. Here is the Association of Personal Injuries Lawyers' response to the call for evidence for the Health and Social Care Select Committee Inquiry. Related reading Patient Safety Learning's response to the NHS Litigation Reform AvMA's response to the NHS Litigation Reform
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Content Article
Patient Safety Learning and the Safer Healthcare and Biosafety Network (SHBN) are undertaking a project, working with patient safety experts and frontline staff, to produce a manual to support staff after a serious safety incident. As part of this work, we are asking healthcare staff to complete a short survey relating to experiences of a serious safety incident. -
Content Article
West Suffolk Review (9 December 2021)
Patient Safety Learning posted an article in Other reports and inquiries
Findings from an independent review, commissioned by NHS Improvement in February 2020, at the request of the Department for Health and Social Care, into the handling of whistleblowing at West Suffolk NHS Foundation Trust. -
Content ArticleThe purpose of this investigation by the Healthcare Safety Investigation Branch (HSIB) is to help improve patient safety in relation to recognition of the acutely ill infant and child, recognising the difficulty in distinguishing between simple viral illnesses and life-threatening bacterial infections in very young patients. This Healthcare Safety Investigation Branch investigation reviewed the case of Mohammad, a baby who had become unwell and was taken to an emergency department by ambulance following a call to NHS 111. He arrived at 8.04pm and was considered to have a mild viral illness, subsequently being transferred to a paediatric observational ward, and discharged at 11.45pm with a diagnosis of likely bronchiolitis. At approximately 3.40am his mother contacted the ward as his condition worsened, which resulted in a 999 call. The ambulance crew did not consider that Mohammad was seriously ill so did not conduct a ‘blue light’ emergency transfer to hospital. Mohammad was admitted to the emergency department at approximately 4.40am and suffered a respiratory and then cardiac arrest at 5:28am, with attempts to resuscitate unsuccessful and stopped at 6:10am. Mohammad died of septicaemia caused by meningococcus (serogroup B) bacteria.
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Content ArticleProviding high-quality care means putting patient safety at the forefront of every action and decision made in the provision of healthcare services. To achieve this requires the conditions of close cooperation, good communication and the application of effective systems, processes and controls - through good governance. This investigation carried out by Niche Health and & Social Care Consulting describes a complex and evolving set of circumstances where these conditions were not met at Morecambe Bay and which played-out negatively over many years, resulting in uncontrolled legacy. A primary objective of this investigation has been to seek a full and validated understanding of any patient harms or clinically untoward outcomes in Urology. Particularly, but not exclusively, to validate concerns raised publicly in the ‘whistleblowing’ publication Whistle in the Wind. The investigation found a multi-faceted set of contributory issues which cannot, in many cases, be singularly applied to individual Consultant failings.
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Content ArticleThe People’s Covid Inquiry, chaired by the human rights lawyer Michael Mansfield QC, began in January 2021 to learn lessons quickly after the government rejected calls for a public inquiry. The Government was informed of the inquiry on 23 February 2021 and invited to take part. No response was received. The first session of the People’s Covid Inquiry began on 24 February and convened in live sessions fortnightly until 16 June 2021. The Inquiry took evidence over nine sessions from over 40 witnesses including international and UK experts, frontline workers, bereaved families, trade union leaders, and representatives of disabled people’s and pensioners’ organisations.
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Content ArticleDr Nick Woodier, HSIB National Investigator, reflects on the challenges associated with joint surgical care of patients and shares learning that can aid the NHS and the private sector as new national agreements come into force.
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Content Article
A case study in denial (Roger Kline, 3 February 2022)
Patient Safety Learning posted an article in Culture
A recent highly critical NHSEI External Review of The Christie NHS Foundation Trust was prompted by whistleblowers. The Review was provided with detailed evidence that there were very significant (and distressing) problems with the Trust’s approach to race discrimination, bullying and the response when concerns were raised. The External Review (Paragraph 2.2.6.) states In this blog, Roger Kline considers whether the Trust’s own data supports the assertions in the Trust Chair’s email to staff in response to the Review. He considers how the NHSEI Review addressed the issues. He suggests that the Trust’s response; the shortcomings of the NHSEI Review response to the issue of race discrimination; and the NHSEI response to the Review once published mean that further scrutiny of the Trust and NHSEI’s response is required if staff are ever again to risk raise legitimate concerns in this Trust – or rely on NHSEI to support staff who do so. -
Content Article
Statement from Sajid Javid, Secretary of State for Health and Social Care, to the House on establishing a Special Health Authority for Independent Maternity Investigations. -
Event
SEIPS in radiology
Sam posted an event in Community Calendar
untilThe Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply SEIPS. This 3 hour masterclass will focus upon using SEIPS in radiology. The SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these masterclass sessions by clinical subject experts. Register -
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SEIPS masterclass in healthcare
Sam posted an event in Community Calendar
The Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply SEIPS. This 3 hour masterclass will focus upon using SEIPS in healthcare. The SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these masterclass sessions by clinical subject experts. Morning session: 9.30-12.30 Afternoon session: 1.30-4.30 Register -
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SEIPS in emergency department
Sam posted an event in Community Calendar
untilThe Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply SEIPS. This 3 hour masterclass will focus upon using SEIPS in Emergency Departments. The SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these masterclass sessions by clinical subject experts. Register -
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SEIPS in social care
Sam posted an event in Community Calendar
untilThe Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply SEIPS. This 3 hour masterclass will focus upon using SEIPS in Social Care. The SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these masterclass sessions by clinical subject experts. Register -
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SEIPS in mental health
Sam posted an event in Community Calendar
untilThe Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply SEIPS. This 3 hour masterclass will focus upon using SEIPS in Mental Health. The SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these masterclass sessions by clinical subject experts. Register -
Event
SEIPS in learning disability
Sam posted an event in Community Calendar
untilThe Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply SEIPS. This 3 hour masterclass will focus upon using SEIPS in Learning Disability. The SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these masterclass sessions by clinical subject experts. Register -
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SEIPS in surgery
Sam posted an event in Community Calendar
untilThe Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply SEIPS. This 3 hour masterclass will focus upon using SEIPS surgery. The SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these masterclass sessions by clinical subject experts. Register -
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SEIPS masterclass in paramedic – Urgent & emergency care
Sam posted an event in Community Calendar
The Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply SEIPS. This 3 hour masterclass will focus upon using SEIPS in paramedic – urgent & emergency care. The SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in this masterclass session by a clinical subject expert. Morning session: 9.30-12.30 Afternoon session: 1.30-4.30 Register -
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Safety for All - Employee investigations webinar
Sam posted an event in Community Calendar
untilEmployee investigations refers to the investigation of allegations made by and against staff. Aneurin Bevan University Health Board (ABUHB) is responsible for the planning, delivery, and commissioning of NHS Wales services for a population of over 660,000 citizens. It employs over 15,000 staff. ABUHB started a programme of work to improve its employee investigations because its HR team identified that during a 15-month period, over 50% of investigations had led to no sanctions for individuals who had been taken through them. Their Employee Wellbeing Service had been concerned about the number of clients who had experienced significant stress and trauma as a result of going through the employee investigation process. The focus of the intervention was to reduce ‘avoidable employee harm’ by reducing the number of employees subjected to investigations, and to reduce the duration of investigations that take place. Andrew Cooper and Liz Rogers from ABUHB will present the case study and report back on the intervention outcomes, key learning points and progress made to date. The webinar will last one hour with time for questions to the presenters. Register -
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HSIB: After Action Review course
Sam posted an event in Community Calendar
This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. You’ll also be directed to specific activities designed to extend and consolidate your knowledge. Register -
Event
HSIB: After Action Review course
Sam posted an event in Community Calendar
This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. You’ll also be directed to specific activities designed to extend and consolidate your knowledge. Register -
Event
HSIB: After Action Review course
Sam posted an event in Community Calendar
This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. You’ll also be directed to specific activities designed to extend and consolidate your knowledge. Register -
Event
HSIB: After Action Review course
Sam posted an event in Community Calendar
This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. You’ll also be directed to specific activities designed to extend and consolidate your knowledge. Register -
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 (PSIRF 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. 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 kate@hc-uk.org.uk hub members receive 20% off. Email info@pslhub.org for discount code. Follow this conference on Twitter @HCUK_Clare #SIMental
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Event
Patient Safety Incident investigations
Sam posted an event in Community Calendar
The Patient Safety Strategy (2019) and Patient Safety Investigation Framework (PSIRF) both outline a fundamental shift in the way that patient safety investigations are conducted. This ‘new era’ in patient safety represents a considerable shift in the way that investigations are conducted, particularly for those NHS Trusts implementing PSIRF. As the Serious Incident Framework (2015) becomes obsolete, how teams select their incidents to investigate will shift away from severity of harm to focusing on pinpointing opportunities to maximising learning. Indeed, under the new arrangements, teams are encouraged to consider utilising a wider range of investigation techniques that will ensure a more proportionate and potentially less time-consuming approach to understanding sub-standard care and failings. With an emphasis on systems thinking and human factors, organisations will need to identify and train expert investigators. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/psirf-masterclass or click on the title above or email kate@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for discount code. -
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. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/serious-incident-investigation-patient-safety or email frida@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #NHSSeriousIncidents
