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Showing results for tags 'Investigation'.
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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 ArticleWhen faced with a ‘human error’ problem, you may be tempted to ask 'Why didn’t these people watch out better?' Or, 'How can I get my people more engaged in safety?' You might think you can solve your safety problems by telling your people to be more careful, by reprimanding the miscreants, by issuing a new rule or procedure and demanding compliance. These are all expressions of 'The Bad Apple Theory' where you believe your system is basically safe if it were not for those few unreliable people in it.
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Community Post
Who should investigate?
Patient Safety Learning posted a topic in Investigations and complaints
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Great blog in Learn from Martin on who should be in an investigation team - the expertise of the team, their roles and responsibilities. Do you agree?- Posted
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Content ArticleThis is part three of a series about the investigation process and human factors in healthcare. Part one looked at the why we investigate an ‘incident’. It concluded that there is only one reason to investigate – and that’s to stop the error occurring again. The idea that human factors is a science – done by science types was introduced. That facts are best collected by a minimum of two investigators. Pictures being our friend, and the cognitive interview concept was introduced. This part focuses on ‘Who’ should investigate and deals with the experience and expertise of the team, their roles and responsibilities in the light of the facts they will collect. This blog is aimed at individual trusts and organisations rather than regulators/national bodies, etc.
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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 ArticleThis powerful blog by Sarah Seddon discusses her experience during a 'fitness to practice' hearing. Sarah is a clinical pharmacist, however , has now found herself as a witness following the tragic death of her son Thomas. This blog explains what it is like for the witness during the process and how it made her feel.
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Content ArticleThe Gosport Independent Panel was set up to address concerns raised by families over a number of years about the initial care of their relatives in Gosport War Memorial Hospital and the subsequent investigations into their deaths. The Report is an in-depth analysis of the Gosport Independent Panel’s findings. It explains how the information reviewed by the Panel informed those findings and illustrates how the disclosed documents add to public understanding of events at the hospital and their aftermath.
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Content ArticleAn independent review into the widespread failings by Liverpool Community Health Trust. The review conducted by Dr Bill Kirkup CBE, commissioned by NHS Improvement, looks into the issues at the Trust from November 2010 to December 2014. It also looks at the oversight of the Trust by the NHS Trust Development Authority, NHS England and commissioners.
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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 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 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 ArticleThe Healthcare and Safety Investigation Branch (HSIB) identified a significant safety risk posed by the communication and transfer of information between secondary care, primary care and community pharmacy relating to medicines at the time of hospital discharge. A reference event was identified that resulted in a patient inadvertently receiving two anticoagulant medications at the same time, possibly causing an episode of gastrointestinal (digestive tract) bleeding. Increasingly, healthcare facilities in primary and secondary care are introducing digital solutions (electronic prescribing and medicines administration (ePMA) systems) to improve medicines safety. However, analysis of the reference event identified how ePMA systems can create their own risks – risks that will need to be addressed as these systems become more widespread. Other risk factors relating to prescribing and the discharge of the patient, including medicines reconciliation, availability of pharmacy services and weekend working, were identified during the investigation.
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Content ArticleConcern was raised about a number of deaths at Furness General Hospital leading to the establishment of the Morecambe Bay Investigation in September 2013, led by Dr Bill Kirkup. In May 2018 the Professional Standards Agency published a ‘Lessons Learned Review’ into the handling of concerns relating to the fitness to practise of nurses in Furness General Hospital (now part of the University Hospitals of Morecambe Bay NHS Foundation Trust) by the Nursing and Midwifery Council (NMC). Amongst other issues, the report identified problems with the handling of a document produced by the father of one of the babies who died at Furness General Hospital. In August 2018, the NMC commissioned Verita to carry out an independent audit to review the way the NMC handled the chronology. The audit was asked to focus on the NMC’s systems and processes in order to establish what happened to the chronology and to identify learning for the NMC from the case. Verita is a consultancy specialising in the management and conduct of investigations, reviews and inquiries. Peter Killwick and Kieran Seale carried out the investigation which was supported by Bethany Simpson.
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Content ArticleROSPA's one-day accident investigation training will give you a broad understanding of the accident investigation process, looking at the benefits of accident prevention and putting the emphasis on practical training exercises and real-life case studies. Training is suitable for line managers, supervisors, safety representatives – and anyone with the responsibility for investigating accidents. It will enable organisations to meet their moral and legal obligations to investigate accidents and incidents and learn from safety failure.
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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 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.
