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Showing results for tags 'Investigation'.
Found 1,563 results
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Content ArticleAt a time of increasing regulatory scrutiny and medico-legal risk, managing serious clinical incidents within primary care has never been more important. Failure to manage appropriately can have serious consequences both for service organisations and for individuals involved. This is the first book to provide detailed guidance on how to conduct incident investigations in primary care. The concise guide: explains how to recognise a serious clinical incident, how to conduct a root cause analysis investigation, and how and when duty of candour applies covers the technical aspects of serious incident recognition and report writing includes a wealth of practical advice and 'top tips', including how to manage the common pitfalls in writing reports offers practical advice as well as some new and innovative tools to help make the RCA process easier to follow explores the all-important human factors in clinical incidents in detail, with multiple examples and worked-through cases studies as well as in-depth sample reports and analysis. This book offers a master class for anyone performing root cause analysis and aiming to demonstrate learning and service improvement in response to serious clinical incidents. It is essential reading for any clinical or governance leads in primary care, including GP practices, 'out-of-hours', urgent care centres, prison health and NHS 111. It also offers valuable insights to any clinician who is in training or working at the coal face who wishes to understand how serious clinical are investigated and managed.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) recently published a report that highlighted the fact that poorly implemented ePMA (electronic prescribing and medicines administration) systems can result in potentially fatal medication errors. The report comes after HSIB looked at the case of 75-year old Ann Midson, who was left taking two powerful blood-thinning medications after a mix-up at her local hospital where she was receiving treatment whilst suffering from incurable cancer. PRAC+TICE caught up with Scott Hislop and Helen Jones, two of the investigators, on this podcast to discuss the series of events that ultimately culminated in the sad passing of Mrs Ann Midson.
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Content ArticleJo Wailling is a registered nurse and research associate with the Diana Unwin Chair in Restorative Justice, Victoria University of Wellington. Jo presented on restorative practice at the Commission’s mental health and addiction (MHA) quality improvement programme workshop held in Wellington on 26 June for mental health and addiction leaders. This blog is a continuation of that presentation.
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Content ArticleThe nature and consequences of patient and family emotional harm stemming from preventable medical error, such as losing a loved one or surviving serious medical injury, is poorly understood. Patients and families, clinicians, social scientists, lawyers, and foundation/policy leaders were brought together to establish research priorities for this issue. I recommend that all those involved in 'engagement with harmed patients and families' read this and in particular, commit to making sure they are doing the '20 things organisations can do now' that is listed in table 3. This paper was published in the Joint Commission Journal on Quality and Patient Safety. Register for free to view the full article.
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Content ArticleWhen a serious incident occurs, it is vital that the investigation process is thorough and can withstand scrutiny. Getting to the heart of what went wrong and putting solutions in place to reduce the chances of a repeat incident requires an acute focus on the whole investigation process. Experienced investigator, Chris Brougham, who previously worked at the National Patient Safety Agency, shares her thoughts on what a high quality investigation actually looks like and how you can go about achieving that.
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Content ArticleEighteen years after the advent of the National Patient Safety Agency (NPSA) why is investigating in such a parlous state? Ed Marsden, Managing Director of independent investigative consultants Verita, discusses why making improvements to patient safety comes second place to sorting out problems with the investigative process.
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Content ArticleHealth and social care providers internationally are heavily scrutinised by external regulators as part of accreditation, inspection and external review processes. The aims are generally to identify poor performance and/or to improve performance and in particular to ensure the delivery of good quality services. This can result in a complex, costly and overlapping network of oversight arrangements. In his editorial, published by the Journal of Health Services Research & Policy, Sheldon discusses this topic further.
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Content ArticleThis perspective from the US discusses problems with the use of root cause analysis (RCA) in healthcare. The authors summarise research examining the process and share recommendations to enhance the use of RCAs from the National Patient Safety Foundation document RCA2: Improving Root Cause Analyses and Actions to Prevent Harm.
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Content ArticleIn the past decade, hospitals and healthcare workers have become more familiar with medical errors and the harm they can cause. As a result, incident investigation has become a routine part of the hospital's response to an adverse event. Armed with the results of these investigations, research and quality improvement efforts are now taking on system improvements required to create a safer healthcare environment. There has also been increased attention paid to the appropriate handling of patients and families harmed by medical errors. There is developing recognition that disclosure of adverse events is necessary if hospitals are to learn from mistakes and improve patient safety outcomes. A growing number of accrediting and licensing bodies, as well as governmental entities and professional organisations, have stated the expectation that patients should be told about harmful medical errors. However, progress has been slower in translating policy into action at the level of the frontline clinician. Are these policies also beneficial to physicians and other healthcare workers, many of whom are already struggling just to get their work done? Wu and Steckelberg discuss this further in an Editorial published in BMJ Quality and Safety.
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Content ArticleThe aim of this systematic review from Lawton et al., published in BMJ Quality & Safety, was to develop a ‘contributory factors framework’ from a synthesis of empirical work which summarises factors contributing to patient safety incidents in hospital settings.
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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.
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Content ArticleOne important strategy for system-wide safety improvement involves investigating and addressing the system-wide sources of risk that contribute to unsafe care. Carl MaCrae in his paper published in the Journal of the Royal Society of Medicine highlights five strategies to ensure patient safety investigations actually improve patient safety.
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Content ArticleThis is the report of the Parliamentary and Health Service Ombudsman (PHSO) second investigation into the Care Quality Commission’s (CQC) regulation of the Fit and Proper Persons Requirement (FPPR). Rob Behrens wrote to Dr Sarah Wollaston MP and Chair of the Health and Social Care Select Committee to share the findings from the report. He underlines the need for reform of the FPPR system and for the recommendations from the Kark review to be swiftly implemented.
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Content Article
Our son's final days: "It was like he didn't matter"
Patient Safety Learning posted an article in Patient stories
Mark Stuart spent five days in agony and died following a catalogue of failings by NHS staff. His parents say they have been battling for answers for four years. They tell their story to BBC News. -
Content ArticleIn our Blueprint for Action, we outline some of the concerns around the quality of investigations.
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Content ArticleA workbook published by Health and Safety Executive (HSE), for employers, unions, safety representatives and safety professionals.
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Content ArticleAccident investigations should consider why human failures occurred. Finding the underlying (or latent, root) causes is the key to preventing similar accidents.
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Content ArticleA report from the Public Administration Select Committee looking at the investigation process, how it impacts those involved and how risk can be reduced through learning.
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Content ArticleIn our previous blog we shared some reflections about the recent case of Dr Gawa-Barba and the implications the case has for the promotion of a learning culture in healthcare. In light of the Gawa-Barba case, the Government set up a review to which we have submitted a paper.
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Content ArticleThis report from the Parliamentary Health Service Ombudsman (PHSO) explains the findings of their research, highlights the issues they have identified and sets out the action they believe needs to be taken to improve the quality of NHS investigations.
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Content ArticleThe Parliamentary and Health Service Ombudsman (PHSO) use clinical advice as a key source of evidence to inform their thinking in around three quarters of their health investigations. It is crucial that they commission and use clinical advice correctly. It is also important that those involved in a complaint understand and have confidence in the way it has informed decisions. To meet a commitment they made in their new strategy for 2018-21, the PHSO carried out a major review of the way they use clinical advice when they investigate NHS complaints.
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Content ArticleDr Helen Higham, Co-Director of the Patient Safety Academy, presented at the 'A New Strategy for Patient Safety - Insight, Involvement, Improvement' conference on how we can effectively learn from serious incidents.
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Content ArticleHelen Jones, National Investigator at Healthcare Safety Investigation Branch (HSIB), presented at the recent Patient Safety Strategy Discussion Forum. Helen's presentation focused on how the Patient Safety Incident Response Framework (PSIRF) will run alongside the investigation expertise at HSIB and the implications of the proposed changes set out in the Health Service Safety Investigations Bill. She shared the recommendations that HSIB have made and the delegates discussed the accountability framework for their implementation as this is outside of HSIB’s current remit.
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Content ArticleOn the 18 November 2019, Health Law from Browne Jacobson LLP hosted a Patient Safety Strategy Discussion Forum. This was focused on discussing the key proposals within the NHS Patient Safety Strategy, published in July 2019, and what they mean in practical terms. It also provided an opportunity for Trusts to share and hear about the work being done by others to implement the Strategy. The event was attended by a number of leading patient safety and quality experts and investigators from across the Midlands.
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Content ArticleThis thought paper from Carl Macrae and Charles Vincent explores how healthcare systems can develop a system-wide approach to investigating and learning from the most serious patient safety issues, and examines the organisational infrastructure that is needed to support this. Many safety critical industries depend on the work of an independent, national safety investigator to investigate the most serious risks that span the system and to develop safety recommendations that target any and all organisations that need to work together to address those risks–from front-line providers to regulators. This paper defines the fundamental principles, the practical challenges and the considerable opportunities that any healthcare system must grapple with in the development of a national safety investigator that supports system-wide learning.
