Search the hub
Showing results for tags 'Investigation'.
Found 1,563 results
-
Event
Names matter: Investigation science – Human Factors heresy?
Sam posted an event in Community Calendar
A team of educators from the Investigation Education, Learning & Standards department at the Healthcare Safety Investigation Branch (HSIB) will discuss why they believe investigation is emerging as science in its own right. It’s described by Dawn Benson at the HSIB as “the adoption of a scientific approach to the development to all aspects of investigation practice, education, policy and research”. When in post as a national investigator at HSIB, Dawn noticed that the mix of expertise, knowledge and experience of her colleagues was heterogeneous and included psychology, sociology, systems engineering, human factors, medicine and the sciences of safety, management, improvement, implementation and education. All of which are needed for safety investigations which seek to enable organisations to learn from past experience in order to improve their safety performance. The team from HSIB, Dawn Benson, Rich McMaster, Laura Pickup and Deinniol Owens will also explain why they’ve stopped talking about human factors despite it forming much of what they do. Join us to debate and explore these areas. Helen Vosper will be your chair. Register -
EventHave you been invited to participate in an HSIB maternity investigation? Are you unsure of what the programme is about? Do you have questions about HSIB maternity investigations? This webinar is primarily aimed at doctors in training but will be of interest to clinicians from any professional background and especially to those working within maternity and neonatal services. You will gain a high level overview of the programme, an understanding of our system approach to healthcare safety investigations and information about our investigation methodology. There will be a panel discussion at the end where you will have the opportunity to have any outstanding questions answered. 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) which has now been published for the early adopter sites as introductory guidance. NHS Improvement will then work with a small number of early adopters to test implementation. For all other organisations the PSIRF is being published for information only and using learning from the pilot sites, resources and guidance will be developed to support organisations to adopt and implement PSIRF, with an expectation that providers and local systems will begin transitioning to the PSIRF from Spring 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. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/serious-incident-investigation-learning 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
-
Event
Deteriorating Patient Summit
Patient Safety Learning posted an event in Community Calendar
The Deteriorating Patient Summit focuses on recognising and responding to the deteriorating patient through improving the reliability of patient observations and ensuring quality of care. The conference will include National Developments including the recent recommendations from the Royal College of Physicians 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 conference will include practical case study based sessions on identifying patients at risk of deterioration, improving practice in patient observations, responding to the deteriorating patient, improving escalation and understanding success factors in escalation, sepsis & covid-19, involving patients and families in recognising deterioration, and improving the communication and use of NEWS2 not only in an acute setting but also in the community and at the interface of care. 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 member receive a 20% discount. Email info@pslhub.org for the code. Follow on Twitter @HCUK_Clare #deterioratingpatient -
EventuntilProfessor Pascale Carayon, the author of the Systems Engineering Initiative for Patient Safety (SEIPS), will talk about the development, history and use of SEIPS in healthcare. SEIPS is one of the most widely recognised and used human factors and ergonomics (HFE) approaches within the field of patient safety. The model is widely used to understand how complex socio-technical systems such as healthcare work. SEIPS places the patient at the centre of the system. It enables the description of the parts of the system (people, environments, tools, tasks, processes and outcomes), and how these interact to create safety, efficiency and effectiveness. SEIPS can also be used by practitioners to identify the deficiencies in a healthcare system which impact the ability to deliver high quality and safe care. SEIPS can also be used to contribute to the design of systems and processes. This event will focus on the practical application of SEIPS within healthcare and speakers include: Prof. Pascale Carayon - The SEIPS journey - developing, expanding and deepening the model Chris Hicks and Andrew Petrosoniak - St Michaels Hospitals Toronto - How simulation can break the shackles of bad design Gill Smith - Kaizen Kata - The effectiveness of SEIPS during Covid19 in ICU Jonathan Back - HSIB's Safety Incident Research database Prof. Tom Reader - University of Nottingham Prof. Richard Holden - Indiana University School of Public Health Register
-
Event
Next steps for improving patient safety in the NHS
Sam posted an event in Community Calendar
This Westminister Forum conference from will examine policy priorities for improving patient safety in the NHS in light of forthcoming regulatory changes and plans to tackle key areas of concern through the updated Patient Safety Strategy. It will be an opportunity to discuss patient safety during COVID-19 and how best to drive improvements in the recovery from the pandemic, as well as the impact of recent developments including: the recently introduced Health and Care Bill, which includes measures aiming to strengthen the role of the Healthcare Safety Investigation Branch in improving patient safety an updated Patient Safety Strategy, including a new commitment to developing understanding of how patient safety can contribute to tackling health inequalities. Keynote contributions from Keith Conradi, Chief Investigator, Healthcare Safety Investigation Branch and Natasha Swinscoe, National Patient Safety Lead, AHSN and Chief Executive Officer, West of England AHSN. The agenda is structured to bring out latest thinking on: policy priorities - ensuring patient safety across the health and care system, and identifying areas for improvement the Healthcare Safety Investigation Branch - the evolving role of the HSIB, and the potential impact of proposed reforms patient safety during COVID-19 - improving continuity of care, the uptake of technology and innovative practice, and informing the future NHS approach developing a focus on patient safety: learning from previous failures embedding a focus on patient safety across the health and care system the role of the Patient Safety Commissioner and Patient Safety Specialists the health and care workforce - meeting training needs around patient safety, developing processes for early intervention, and the role of leadership and management in supporting culture change. Register -
Event
A practical guide to Serious Incident Investigation & Learning
Sam posted an event in Community Calendar
This 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) which has now been published for the early adopter sites as introductory guidance. This conference will enable you to: Network with colleagues who are working to improve the investigation of serious incidents. Ensure your approach to Serious Incident Investigation is in line with the NHS Patient Safety Strategy. Update your knowledge with national developments including the New Patient Safety Incident Response Framework. Understand developments in the PSIRF early adopter sites. Reflect on the management and investigation of serious incidents involving COVID-19. Learn from outstanding practice in the development of serious incident investigation and mortality review. Reflect on the perspectives of a patient who has been involved in a serious incident. Develop a risk based response to incident investigation. Reflect on the development of mortality governance within your organization and understand the challenges of COVID-19. Understand how to work with staff to ensure a focus on learning and continuous improvement. Develop your skills in Serious Incident Investigation: applying the human factors to move the focus of investigation from acts or omissions. of staff, to identifying systems improvement. Identify key strategies for improving investigation of serious incidents. Gain CPD accreditation points contributing to professional development and revalidation evidence. Register -
Event
Root Cause Analysis: 1 day masterclass
Sam posted an event in Community Calendar
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. 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. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/root-cause-analysis-1-day-masterclass or email nicki@hc-uk.org.uk hub members receive a 20% discount. Please email info@pslhub.org for discount code -
Event
Clinical negligence: Update for clinicians & managers
Sam posted an event in Community Calendar
This conference, which is Chaired by Simon Hammond, Director of Claims Management, NHS Resolution, will update clinicians and managers on clinical negligence with a particular focus on current issues and the COVID-19 pandemic and the impact on clinical negligence claims. Featuring leadings legal experts, NHS Resolution and experienced clinicians the event will provide an update on current claims the conference will discuss why patients litigate, The Coronavirus Act 2020 and Clinical Negligence Scheme for Coronavirus, responding to claims regarding COVID-19 and the implications of the coronavirus clinical negligence claims protocol. There will be an extended masterclass on trends in clinical negligence claims and responding to claims followed by an extended focus on Maternity Claims. The conference will close with a case study on the advantages of bringing together complaints, claims and patients safety investigation, and practical experiences of coronavirus complaints and claims at an NHS Trust – including understanding the standard of care on which services should be judged, and a final session on supporting clinicians when a claim is made against them. For more information visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/clinical-negligence or email kate@hc-uk.org.uk hub members receive a 20% discount. Please email info@pslhub.org for discount code Follow the conversation on Twitter #clinicalnegligence -
Event
CANDOR Part III: Evaluating CANDOR implementation
Sam posted an event in Community Calendar
Panelists will discuss the key elements for successful CANDOR implementation after robust organisational current state assessment. Methods for timely and comprehensive reporting, steps for event investigation and analysis, alignment of ongoing education with communication, strategies to reduce caregiver burnout through peer support, and elements for CANDOR sustainability are recommended. Register -
EventJoin the Patient Safety Movement for a unique opportunity to view the award-winning HBO hit film Bleed Out and talk with the filmmaker, Steve Burrows afterwards. Bleed Out is the harrowing HBO feature documentary film that explores how an American family deals with the effects of medical malpractice. After Judie Burrows goes in for a routine partial hip replacement and comes out in a coma with permanent brain damage, her son, Steve Burrows, sets out to investigate the truth about what really happened. The documentary film takes place in real time over a span of ten years. Tickets
-
EventuntilThe Healthcare Safety Investigation Branch (HSIB) would like to invite you to their webinar marking the launch of the new report ‘Management of chronic asthma in children aged 16 years and under’. Asthma is the most common lung disease in the UK, and diagnosis and management of the condition, particularly in children and young people can be complex. The case study in our investigation features a 5 year old who had a near fatal asthma attack. In this webinar you will hear from families, our HSIB investigators and from experts in respiratory illness including Dr Jen Townshend and Professor Andrew Bush. The webinar will provide an opportunity for you to explore in greater depth our findings, what we are recommending to improve the outcomes of children and young people with asthma, and give you an opportunity to ask questions. This webinar will help you understand how HSIB’s experience can be applied to your own healthcare setting, as well as finding out what work will be undertaken nationally to implement our recommendations. 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) which has now been published for the early adopter sites as introductory guidance. NHS Improvement will then work with a small number of early adopters to test implementation. For all other organisations the PSIRF is being published for information only and using learning from the pilot sites, resources and guidance will be developed to support organisations to adopt and implement PSIRF, with an expectation that providers and local systems will begin transitioning to the PSIRF from Spring 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. Register
-
EventSafe healthcare depends on factors spanning the entire healthcare system. We know that adverse events will occur and the reasons are seldom simple. Improving patient safety and learning depends on investigating, understanding, and addressing the complex networks of causal factors at all levels. Norway and England have established national independent investigation bodies to support learning and system improvement. The talk looks into the rationale, expectations and practice in this new area in healthcare. Register
-
EventThe NHS is the world’s first health organisation to publish data on avoidable deaths. The National Guidance on Learning from Deaths has driven a strengthening of systems of mortality case review with emphasis on learning. 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. This National Conference focuses on improving the investigation and learning from deaths in NHS Trusts and will reflect on learning from deaths involving COVID-19 and how mortality investigation should be managed in these cases. The conference, chaired by Dr Martin Farrier Clinical Director for Quality & Consultant Paediatrician Wrightington, Wigan and Leigh NHS Foundation Trust, will discuss the role of Medical Examiners in learning from deaths. Download brochure Register
-
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 has now been published for the early adopter sites as introductory guidance, and will examine how this will fit with the Royal College of Psychiatrists Care Review Tool for mortality review. A 20% discount is currently available. Quote HCUK20dmh when booking. Register
-
Event
Simulation in healthcare incident investigation
Sam posted an event in Community Calendar
untilThe NHS standards for patient safety investigation recognise a need to better train and professionalise incident investigation in the NHS. Simulation is commonly utilised to improve the technical and non-technical skills of clinical staff in the NHS and forms part of professional investigation training and practise within other safety critical industries. A scoping review has considered what published work exists in commenting on the use of simulation as a training or practical tool in healthcare incident investigation. There may now be opportunities for healthcare incident investigation to learn from clinical colleagues, and professional investigation colleagues in other safety critical industries, to utilise simulation to help professionalise incident investigation in the NHS. Further information -
EventThe NHS is the world’s first health organisation to publish data on avoidable deaths. The National Guidance on Learning from Deaths has driven a strengthening of systems of mortality case review with emphasis on learning. 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. This National Conference focuses on improving the investigation and learning from deaths in NHS Trusts following the National CQC and NQB guidance, and Department of Health reporting requirements. The conference will also discuss the role of Medical Examiners providing a national system of medical examiners will be introduced to provide much-needed support for bereaved families and patient safety. Further information and to book your place or email nicki@hc-uk.org.uk Follow the conversation on Twitter #CQCDeathsreview We are pleased to offer hub members a 10% discount. Email: info@pslhub.org for the code.
-
Content Article
In this blog, Patient Safety Learning reflects on a recent letter by Keith Conradi to the Secretary of State for Health and Social Care, highlighting concerns about a lack of interest and attention in the activities of the Healthcare Safety Investigation Branch (HSIB) at the highest levels of the Department of Health and Social Care (DHSC) and NHS England.- Posted
- 2 comments
-
1
-
- (and 3 more)
-
Content ArticleIn two videos, Mark Fewster, Head of Product and Innovation at Radar Healthcare, talks to Marcos Manhaes, NHS Improvement, and Paul Ewers, Milton Keynes University Hospitals NHS Trust, about the journey from the National Reporting and Learning System (NRLS) to Learn from Patient Safety Events (LFPSE) and the future benefits the NHS could see.
-
Content ArticleContinuing the 'Why investigate' series, in this blog, Martin Langham looks at collecting data, introduces the idea of measurement, and asks what published science is there for testing it ‘beyond reasonable doubt’.
-
Content Article
In this blog Patient Safety Learning considers the safety concerns highlighted by a recent report by the Healthcare Safety Investigation Branch (HSIB) into the administration of high-strength insulin from pen devices in hospitals. This blog argues that without specific and targeted recommendations to improve patient safety in this area, patients will continue to remain at risk from similar incidents. -
Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation aims to help improve patient safety in relation to administering high-strength insulin from a pen device to patients with diabetes in a hospital setting. As its ‘reference case’, the investigation uses the experience of Kathleen, a 73 year old woman with type 2 diabetes who received two recognised overdoses of insulin while she was in hospital. On both occasions she became hypoglycaemic, received medical treatment, and recovered. Patient Safety Learning has published a blog reflecting on some of the key patient safety issues highlighted in this report.
-
Content ArticleIn this editorial, published in the British Journal of Hospital Medicine, Dr Paul Grime reviews the report 'Mind the implementation Gap: The persistence of avoidable harm in the NHS', which calls on the government, parliamentarians and NHS leads to take action to address the underlying causes of avoidable harm in healthcare.
- Posted
- 1 comment
-
- (and 7 more)
-
Content ArticleThis blog considers the similarities and differences between the Healthcare Safety Investigation Branch in England and Ukom, the Norwegian Healthcare Investigation Board. Both are independent national organisations, which take a no blame approach to patient safety investigations, however they also have a number of distinct differences in their approach.
- Posted
- 1 comment
-
- (and 1 more)
