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Showing results for tags 'Patient safety incident'.
Found 684 results
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EventThe Patient Safety Incident Response Framework (PSIRF) sets out a new approach to learning and improving following patient safety incidents across the NHS in England. Transition webinars focus on the different phases of the PSIRF preparation guide and feature presentations from NHS organisations currently transitioning to PSIRF. Presenters: Tracey Herlihey, Head of Patient Safety Incident Response, NHS England Lauren Mosley, Head of Patient Safety Implementation, NHS England TBC Further information
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EventuntilThe Patient Safety Incident Response Framework (PSIRF) sets out a new approach to learning and improving following patient safety incidents across the NHS in England. This workshop will focus on the principles of incident response planning for all providers, including mental health, acute, community, ambulance, and maternity. Further information
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EventThe Patient Safety Incident Response Framework (PSIRF) sets out a new approach to learning and improving following patient safety incidents across the NHS in England. Transition webinars focus on the different phases of the PSIRF preparation guide and feature presentations from NHS organisations currently transitioning to PSIRF. Presenters: Tracey Herlihey, Head of Patient Safety Incident Response, NHS England Lauren Mosley, Head of Patient Safety Implementation, NHS England, Charity Mutiti, Patient Safety Specialist, NHS South West London ICB Marsha Jones , Deputy Chief Nurse, Epsom and St Helier University Hospitals NHS trust Jeni Deborah Mwebaze, Director of Quality, Croydon Health Services NHS Trust Patricia Goldrick, Senior Patient Safety and Improvement Manager, Croydon Health Services NHS Trust Further information
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EventThis one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. These masterclasses have been designed to align with the new Patient Safety Syllabus and subsequent Patient Safety Incident Response Framework (PSIRF). We will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/systems-approach-patient-safety-masterclass or email kate@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for discount code.
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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. The conference update delegates on the new Patient Safety Incident Response Standards and how to review your current practice against these standards. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/serious-incident-investigation-patient-safety or email kate@hc-uk.org.uk.. hub members receive a 20% discount. Please email info@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #NHSSeriousIncidents
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EventuntilThis virtual workshop from the Institute for Safe Medication Practices Canada will provide healthcare professionals with background theory and hands-on practice in incident analysis using Root Cause Analysis (RCA) and in proactive risk assessment using Failure Mode and Effects Analysis (FMEA). Register
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EventuntilThis virtual workshop from the Institute for Safe Medication Practices Canada will provide healthcare professionals with background theory and hands-on practice in incident analysis using Root Cause Analysis (RCA) and in proactive risk assessment using Failure Mode and Effects Analysis (FMEA). Register
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EventuntilThis virtual workshop from the Institute for Safe Medication Practices Canada will provide healthcare professionals with background theory and hands-on practice in incident analysis using Root Cause Analysis (RCA) and in proactive risk assessment using Failure Mode and Effects Analysis (FMEA). Register
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Learning from Never Events
Patient Safety Learning posted an event in Community Calendar
Never events are defined as “serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations.” They are designed to act as a red flag for improvement by NHS organisations. This one day masterclass will focus on safety culture around Never Events within healthcare organisations. There were 364 never events in 2020/21 and 349 between April 2021 and Jan 2022. The masterclass will look at how Never Events have been investigated and at Human Factors approaches to improving learning and the systems to reduce harm. It will compare our experiences with learning from serious incidents from other countries. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/learning-from-never-events or email kate@hc-uk.org.uk. hub members receive a 20% discount, Email info@pslhub.org for discount code. -
EventuntilThe NHS England National Patient Safety Team are hosting two workshops to support Integrated Care Boards to prepare to transition to the new Patient Safety Incident Response Framework (PSIRF). The workshops will be held across two dates Monday 16 January 2023 and Tuesday 17 January 2023 to create smaller group sizes for discussion. The content will be the same across both dates. The webinar will cover: Introduction and latest updates on PSIRF. How oversight changes under PSIRF. The new role of the ICB. Working collaboratively with providers. Training requirements. Q&As. Speakers: Tracey Herlihey, Head of Patient Safety Incident Response Policy, NHS England Lauren Mosely, Head of Patient Safety Implementation, NHS England. Register
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EventuntilThis is the second in a series of practical webinars from NHS England to support organisations to transition to the Patient Safety Incident Response Framework (PSIRF). Following the PSIRF preparation guide, this webinar coincides with the transition from the ‘Discovery and diagnostic’ phase, to the ‘Governance and quality monitoring’ phase. The agenda includes: Update from the national patient safety team. Look back at the ‘Diagnostic and discovery’ phase and look forward to the ‘Governance and quality monitoring phase’ with examples of challenges and successes. Speakers: Tracey Herlihey, Head of Patient Safety Incident Response Policy Lauren Mosley, Head of Patient Safety Implementation Dr Tanya Claridge, Acting Group Director of Clinical Governance, Manchester University NHS Foundation Trust Stephen Tipper, Chartered Ergonomist and Human Factors Specialist, Human Factors Programme Manager, University Hospitals Coventry and Warwickshire NHS Trust Register
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EventThe publication of the New Patient Safety Incident Response Framework in August 2022 has shifted the focus towards identifying and investigating patient safety incidents and events that have the greatest potential to lead to learning and improvement. This conference focuses on patient safety learning – maximising learning and improvement from patient safety insight and events. The conference will support you to identify incidents and insight that has the greatest potential for improvement and use a range of system-based approaches for learning from patient safety incidents. The conference will also update delegates on the new Learn from patient safety events (LFPSE) service and how local incident reporting will adapt to this new system. The roles and competencies of the Learning Response Lead, and the practicalities of involving and engaging with patients to deliver continuous improvement will also be discussed. Finally the conference will share examples of Safety Actions & After Action Reviews which is recommended under the new framework. This conference will enable you to: Network with colleagues who are working to improve the learning from Patient Safety Insight and Events. Update your knowledge on the New Patient Safety Incident Response Framework published in August 2022. Ensure your approach to learning is in line with PSIRF. Understand the new roles of Patient Safety Partner, Patient Safety Specialist and Learning Response Lead. Identifying and prioritise incidents that have the greatest potential for learning. Explore the requirements and value of the Learn from patient safety events (LFPSE) service. Reflect on the perspectives of a patient who has been engaged as a patient safety partner, and understand how to engaging and involving patients, families and staff can lead to improvement. Understand behaviours, decisions and actions that allow continuous learning and improvement. Develop practical approaches to better aligning the work of patient safety and quality improvement teams. Understand how to work with staff to ensure a focus on learning and continuous improvement. Develop your skills in Leading Patient Safety Improvement and techniques for ensuring a system-based approach to learning. Identify key strategies for delivering Safety Actions & After Action Reviews: Delivering, accountability and monitoring. Supports CPD professional development and acts as revalidation evidence. This course provides 5 hours training for CPD subject to peer group approval for revalidation purposes. Register We have five free places for hub members. To secure the places, simply quote HCUK00PSL.
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EventThis conference focuses on patient involvement and partnership for patient safety including implementing the New National Framework for involving patients in patient safety, and developing the role of the Patient Safety Partner (PSP) in your organisation or service. The conference will also cover engagement of patients and families in serious incidents, and patient involvement under the Patient Safety Incident Response Framework published in August 2022. This conference will enable you to: Network with colleagues who are working to involve patients in improving patient safety. Reflect on patient perspective. Understand the practicalities of recruiting Patient Safety Partners. Improve the way you recruit, work with and support Patient Safety Partners, Develop your skills in embedding compassion and empathy into patient partnership. Examine the role of patients under the new Patient Safety Incident Response Framework (PSIRF). Understand how you can improve patient partnership, family engagement and involvement after serious incidents. Identify key strategies for support patients, their families and carers to be directly involved in their own or their loved one’s safety. Learn from case studies demonstrating patient partnership for patients safety in action. Examine methods of involving patients to improve patient safety in high risk areas. Self assess and reflect on your own practice. Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
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The future of healthcare investigations
Patient Safety Learning posted an event in Community Calendar
untilThis free webinar will explore what the future looks like for this critical area of human factors investigation. The presenters will each talk about a different aspect and there will be time for you to ask questions. The future of healthcare investigation: focus on learning and improvement Mark Sujan will talk about the new NHS England Patient Safety Incident Response Framework (PSIRF) which puts emphasis on learning and improvement. You’ll hear about the limitations of existing approaches to learning from incidents in healthcare, which PSIRF tries to overcome. You’ll then find out about the principles of organisational learning for achieving sustainable change, based on the CIEHF guidance. Transition: HSIB to HSSIB and MNSI HSIB’s Deinniol Owens will reveal that in April 2023, the Healthcare Safety Investigation Branch (HSIB) will transition into two new organisations: The Health Services Safety Investigation Body (HSSIB) and the Maternity and Newborn Safety Investigations (MNSI) Special Health Authority. You’ll get insight into the roles of the new organisations and hear about the additional focus on the new powers and opportunities available to HSSIB now that it’s been confirmed in statute by the Health and Care Act 2022. Investigation education: The transfer of knowledge Andrew Murphy-Pittock will explore one of the key objectives of HSIB, which is to transfer knowledge to those undertaking and overseeing patient safety investigations. You’ll find out how HSIB has developed a flexible, agile programme, working with colleagues at PSIRF, to help healthcare organisations on the move away from the Serious Incident Framework to a systems-focused approach to learning, involving those affected by incidents in the process. You’ll also hear about current and future plans for the education programme. Who will this be of interest to? This webinar should be of interest to healthcare professionals, investigators, change managers, process designers and anyone with an interest in patient safety. Register -
EventFrontline staff often perceive event reporting as a black hole where no information exits once it enters. Join Andy Moyer, BSN, RN-BC, patient safety informatics specialist at Penn State Health Milton S. Hershey Medical Center, where he will help you tackle this perception by providing reporters better feedback. Moyer will also demonstrate ways to increase the quantity and quality of reported events. Register
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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) a version of which has now been published. Local systems and organisations outside of the early adopter areas are free to use the already published version of the PSIRF to start to plan and prepare for PSIRF’s full introduction. 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. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/serious-incident-investigation-patient-safety or email nicki@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for a discount code. Follow on Twitter @HCUK_Clare #NHSSeriousIncidents
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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 was published on 16 August 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, 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. Register
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EventThis one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace and is aligned with the new Patient Safety Syllabus 2021. The new Patient Safety Strategy advises that organisations must adopt a new and broader approach to stimulate learning from patient safety incidents. This course is designed to assist healthcare professionals involved in this important work. The main purpose is to provide learners with a full understanding of the various approaches that can now be used to conduct patient safety incident investigation (PSIIs). Traditionally, root cause analysis has been used as a blanket approach to diagnosing why patient safety have been compromised, but healthcare teams are henceforth being encouraged to adopt a wider range of methods that will both save time and facilitate enhanced learning. The focus is now on appropriate proportionality in response to incidents that occur in their organisation. Key learning objectives: Understand the new patient safety landscape. Understand the need for proportionality of investigation. Learn how to use a range of techniques for conducting PSIIs. Understand how to write an impactful improvement plan. Consider how your current approach to patient safety investigations compares to the agreed national standards. Understand typical pitfalls and traps associated with this wider workstream and tips for avoiding them. Register
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EventSEIPS 2.0 is the most widely used model in human factors in healthcare. This one day masterclass will look at the model itself and how it can be applied to healthcare departments. It will look at real world examples as well as the literature. SEIPS 2.0 is the next-generation healthcare human factors model , which embraces 3 principles of Systems orientation, Person-centeredness and Design-driven improvement. Key learning objectives What is SEIPS 2.0? How does SEIPS link to Patient Safety? How to use SEIPS 2.0 clinically? • How to improve technology? Engaging patients and families Register hub members receive a 20% discount. Email info@pslhub.org
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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) a version of which has now been published and which is being tested in early adopter sites. NHS Improvement is working with these early adopters to test implementation, and analysis of this will inform the final version with the revised framework due in Summer 2022. Local systems and organisations outside of the early adopter areas are free to use the already published version of the PSIRF to start to plan and prepare for PSIRF’s full introduction. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/serious-incident-investigation-patient-safety 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
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EventuntilThe Patient Safety Incident Response Framework (PSIRF) will be published early August 2022, as a major piece of guidance on how NHS organisations respond to patient safety incidents, and ensure compassionate engagement with those affected. Secondary care providers will be asked to begin preparing to transition to PSIRF from September 2022. Preparation is expected to take 12 months with all organisations transitioning to PSIRF by August 2023. This webinar will be hosted on MS Teams Live to provide: An introduction to the Patient Safety Incident Response Framework and accompanying guidance An overview of the next steps for providers as they begin work to prepare to transition to the framework An outline of the six preparation phases over the next 12 months Details of resources and support to help providers prepare for PSIRF Opportunities to ask questions. Presenters: Tracey Herlihey, Head of Patient Safety Incident Response Policy, NHS England National Patient Safety Team Lauren Mosley, Head of Patient Safety Implementation, NHS England National Patient Safety Team Register
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EventJoin this Royal Society of Medicine conference to learn some of the key medico-legal issues that impact upon GPs/primary care. The overarching aim is to improve patient safety in both primary and secondary care via learning from incidents and better understanding the indemnity provisions in place for GPs/primary care and how that feeds back into learning. The aim of this meeting is to review and promote an understanding of recent legal and regulatory developments, with a specific emphasis on inquests, clinical negligence and incidents in the primary care sector, and their impact upon patient safety. Additionally, we will also discuss issues that those in secondary care should also be aware of. Register
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Learning from patient safety incidents
Patient Safety Learning posted an event in Community Calendar
This one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace and is aligned with the new Patient Safety Syllabus 2021. Key learning objectives: Understand the new patient safety landscape Understand the need for proportionality of investigation Learn how to use a range of techniques for conducting PSIIs Understand how to write an impactful improvement plan Consider how your current approach to patient safety investigations compares to the agreed national standards Understand typical pitfalls and traps associated with this wider workstream and tips for avoiding them. 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. They have also authored articles on significant event analysis and clinical audit/quality improvement, all techniques seen as increasingly relevant to improving patient safety. Register -
EventThis on-demand conference focuses on supporting staff who have been involved in patient safety incidents, or are the subject of complaints or claims. Involvement in an incident, complaint or claim can have severe consequences on staff who may experience a range of reactions including stress, depression, shame and guilt. This conference will enable you to: Network with colleagues who are working to support staff following incidents, complaints or claims. Understand national developments including the requirements in the 2020 Patient Safety Incident Response Framework. Reflect on how we can better support staff experiencing these issues through Covid-19. Deliver a just culture that supports consistent, constructive and fair evaluation of the actions of staff involved in patient safety incidents. Reflect on a healthcare’s professionals personal experience of being the subject of an incident investigation. Improve immediate support and debriefing when an incident occurs. Develop your skills in providing the staff member involved in a patient safety incident specific individual support or intervention to work safely. Understand how you can improve processes for ensuring candour and supporting staff. Identify key strategies for interviewing staff and taking statements and preparing staff for Coroner’s Inquests. Ensure you are up to date with the latest developments in psychological support for staff including building resilience. Self assess and reflect on your own practice. Gain CPD accreditation points contributing to professional development and revalidation evidence. For more information https://www.healthcareconferencesuk.co.uk/on-demand-training/patient-safety-incident-complaint-claim or email kerry@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #SupportingClinicians
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Community PostI was just listening to a podcast interview between Dr Rangan Chatterjee and Matthew McConaughey (In the series 'Feel better, live more'). Matthew M. mentioned that he came from a highly resilient family. If someone fell over, his mother would tell them to get right back up straight away and carry on. He added that he thought that while this resilience was generally a good thing, there should be (what he called) a 'loophole' in it so that there was time to learn why they have fallen over to begin with. Was there a crack in the pavement that needed to be avoided? That way, it wouldn't happen again in the future. This made me think about whether there really was a conflict between resilience in organisations and the need to learn from failure. What do you think??
