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Showing results for tags 'Root cause anaylsis'.
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Content ArticleSerious incident management and organisational learning are international patient safety priorities. However, little is known about the quality of suicide investigations and the potential for organisational learning. Suicide risk assessment is acknowledged as a complex phenomenon, particularly in the context of adult community mental health services. Root cause analysis (RCA) is the dominant investigative approach, although the evidence base underpinning RCA is contested, with little attention paid to the patient in context and their cumulative risk over time. This study reviewed research in this area and found that recent literature proposes a Safety-II approach in response to the limitations of RCA.
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- Investigation
- Mental health - adult
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Event
Root Cause Analysis: 1 day masterclass
Patient Safety Learning posted an event in Community Calendar
This intensive masterclass will provide in-house Root Cause Analysis training in line with The NHS Patient Safety Strategy (July 2019). 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. This one-day course is designed to provide delegates with the key skills and knowledge that they will require to conduct Root Cause Analysis effectively. The course content walks learners through the seven-key stages to conducting a high-quality Root Cause Analysis investigation. It pays particular attention to planning and managing investigations, interviewing staff, mapping information, using appropriate analysis tools to establish contributory factors, plus focus on creating fit-for-purpose action plans and final reports. It advocates Root Cause Analysis as a teambased approach and concur with NHS Improvement’s 2018 statement ‘investigations must be led by trained investigators with the support of an appropriately resourced investigation team’. 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. This course 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. -
Event
Root Cause Analysis: 1 day masterclass
Patient Safety Learning posted an event in Community Calendar
This intensive masterclass will provide in-house Root Cause Analysis training in line with The NHS Patient Safety Strategy (July 2019). 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. This one-day course is designed to provide delegates with the key skills and knowledge that they will require to conduct Root Cause Analysis effectively. The course content walks learners through the seven-key stages to conducting a high-quality Root Cause Analysis investigation. It pays particular attention to planning and managing investigations, interviewing staff, mapping information, using appropriate analysis tools to establish contributory factors, plus focus on creating fit-for-purpose action plans and final reports. It advocates Root Cause Analysis as a teambased approach and concur with NHS Improvement’s 2018 statement ‘investigations must be led by trained investigators with the support of an appropriately resourced investigation team’. 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. This course 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. -
Content ArticleIncident investigation remains a cornerstone of patient safety management and improvement, with recommendations meant to drive action and improvement. However, there is little empirical evidence about how—in real-world hospital settings—recommendations are generated or judged for effectiveness.
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- Investigation
- Organisational learning
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Content ArticleEvent analysis is a valuable tool to improve patient safety and quality of care by identifying root causes of incidents and implementing corrective actions to prevent future similar events from occurring. When we analyse adverse events in healthcare and do not incorporate an equity lens, however, we are missing a crucial piece of the investigative puzzle. Health equity is essential to improving health and well-being and can be costly if not addressed as explained in this Institute for Healthcare Improvement (IHI) blog
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- Health inequalities
- Health Disparities
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Content Article
Duty of Candour for Wales
Gethin posted an article in NHS Wales (Gig Cymru)
The Duty of Candour for Wales statutory guidance.- Posted
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- Patient harmed
- Patient / family involvement
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Content ArticleWales' national policy on patient safety incident reporting and management.
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- 1 comment
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- Patient safety incident
- Risk management
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Event
Root Cause Analysis: 1 day masterclass
Patient Safety Learning posted an event in Community Calendar
This intensive masterclass will provide in-house Root Cause Analysis training in line with The NHS Patient Safety Strategy (July 2019). 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. This one-day course is designed to provide delegates with the key skills and knowledge that they will require to conduct Root Cause Analysis effectively. The course content walks learners through the seven-key stages to conducting a high-quality Root Cause Analysis investigation. It pays particular attention to planning and managing investigations, interviewing staff, mapping information, using appropriate analysis tools to establish contributory factors, plus focus on creating fit-for-purpose action plans and final reports. We advocate Root Cause Analysis as a team-based approach and concur with NHS Improvement’s 2018 statement ‘investigations must be led by trained investigators with the support of an appropriately resourced investigation team’. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.- Posted
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- Training
- Root cause anaylsis
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(and 1 more)
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Content ArticleWork to prepare for transition to working within the Patient Safety Incident Response Framework (PSIRF) in the Autumn of 2023 is well underway by healthcare providers across England. Written for all those involved in implementing PSIRF, this article describes some of the reasons behind the challenges being faced and suggests three principles to help navigate through this complex process and offers practical ideas to help.
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- 1 comment
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- PSIRF
- Organisational culture
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Event
Root Cause Analysis: 2 day masterclass
Patient Safety Learning posted an event in Community Calendar
untilThis two day intensive masterclass will provide Root Cause Analysis Training in line with the July 2019 Patient Safety Strategy. This intensive two day masterclass will provide Root Cause Analysis training in line with the 2019 Patient Safety Strategy and subsequent guidance. The course will offer a practical guide to conducting RCA with a focus on systems-based patient safety investigation as proposed within the latest guidance released by NHS England and NHS Improvement. The course provides insights into how RCA is evolving and gives detailed information on what standards RCA investigations are expected to reach following the detailed recent reviews of patient safety work across the NHS and healthcare. The new National Patient Safety Incident Response Framework (PSIRF) published in 2020 highlights important changes to the way safety incidents will be investigated, which is reflected in this course. Key new content includes: Promotion of RCA as a tool for learning & improvement. Emphasis on increased use of listening & interview (staff and patients) to gain a better understanding of what has happened. The importance of Safety II and focusing on system strengths, plus linking RCAs to QI & clinical audit. More emphasis on human factors. Brief information on approaches that may be more appropriate to RCA (e.g. significant event analysis, after-action reviews). Register hub members receive a 20% discount. Email info@pslhub.org for discount code.- Posted
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- Root cause anaylsis
- Training
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(and 1 more)
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Event
Root Cause Analysis: 2 day masterclass
Patient Safety Learning posted an event in Community Calendar
untilThis two day intensive masterclass will provide Root Cause Analysis Training in line with the July 2019 Patient Safety Strategy. This intensive two day masterclass will provide Root Cause Analysis training in line with the 2019 Patient Safety Strategy and subsequent guidance. The course will offer a practical guide to conducting RCA with a focus on systems-based patient safety investigation as proposed within the latest guidance released by NHS England and NHS Improvement. The course provides insights into how RCA is evolving and gives detailed information on what standards RCA investigations are expected to reach following the detailed recent reviews of patient safety work across the NHS and healthcare. The new National Patient Safety Incident Response Framework (PSIRF) published in 2020 highlights important changes to the way safety incidents will be investigated, which is reflected in this course. Key new content includes: Promotion of RCA as a tool for learning & improvement. Emphasis on increased use of listening & interview (staff and patients) to gain a better understanding of what has happened. The importance of Safety II and focusing on system strengths, plus linking RCAs to QI & clinical audit. More emphasis on human factors. Brief information on approaches that may be more appropriate to RCA (e.g. significant event analysis, after-action reviews). Register hub members receive a 20% discount. Email info@pslhub.org for discount code.- Posted
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- Root cause anaylsis
- PSIRF
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(and 1 more)
Tagged with:
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Event
Root Cause Analysis: 1 day masterclass
Patient Safety Learning posted an event in Community Calendar
This intensive masterclass will provide in-house Root Cause Analysis training in line with The NHS Patient Safety Strategy (July 2019). 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. This one-day course is designed to provide delegates with the key skills and knowledge that they will require to conduct Root Cause Analysis effectively. The course content walks learners through the seven-key stages to conducting a high-quality Root Cause Analysis investigation. We pay particular attention to planning and managing investigations, interviewing staff, mapping information, using appropriate analysis tools to establish contributory factors, plus focus on creating fit-for-purpose action plans and final reports. We advocate Root Cause Analysis as a teambased approach and concur with NHS Improvement’s 2018 statement ‘investigations must be led by trained investigators with the support of an appropriately resourced investigation team’. 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. Register hub members receive a 20% discount. Email info@pslhub.org for discount code. -
Event
Root Cause Analysis: 1 day masterclass
Patient Safety Learning posted an event in Community Calendar
This intensive masterclass will provide in-house Root Cause Analysis training in line with The NHS Patient Safety Strategy (July 2019). 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. This one-day course is designed to provide delegates with the key skills and knowledge that they will require to conduct Root Cause Analysis effectively. The course content walks learners through the seven-key stages to conducting a high-quality Root Cause Analysis investigation. We pay particular attention to planning and managing investigations, interviewing staff, mapping information, using appropriate analysis tools to establish contributory factors, plus focus on creating fit-for-purpose action plans and final reports. We advocate Root Cause Analysis as a teambased approach and concur with NHS Improvement’s 2018 statement ‘investigations must be led by trained investigators with the support of an appropriately resourced investigation team’. 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. Register hub members receive a 20% discount. Email info@pslhub.org for discount code. -
Event
Root Cause Analysis: 1 day masterclass
Patient Safety Learning posted an event in Community Calendar
This intensive masterclass will provide in-house Root Cause Analysis training in line with The NHS Patient Safety Strategy (July 2019). 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. This one-day course is designed to provide delegates with the key skills and knowledge that they will require to conduct Root Cause Analysis effectively. The course content walks learners through the seven-key stages to conducting a high-quality Root Cause Analysis investigation. We pay particular attention to planning and managing investigations, interviewing staff, mapping information, using appropriate analysis tools to establish contributory factors, plus focus on creating fit-for-purpose action plans and final reports. We advocate Root Cause Analysis as a teambased approach and concur with NHS Improvement’s 2018 statement ‘investigations must be led by trained investigators with the support of an appropriately resourced investigation team’. 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. Register- Posted
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- Root cause anaylsis
- Training
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EventuntilThis virtual workshop will provide paramedics 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
- Posted
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- Patient safety incident
- Canada
- (and 3 more)
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EventuntilThis virtual workshop will provide paramedics 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
- Posted
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- Canada
- Patient safety incident
- (and 3 more)
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EventuntilThis virtual workshop will provide health care 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
- Posted
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- Patient safety incident
- Risk assessment
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(and 2 more)
Tagged with:
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EventuntilThis virtual workshop will provide health care 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
- Posted
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- Canada
- Risk assessment
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(and 2 more)
Tagged with:
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EventuntilThis virtual workshop will provide health care 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
- Posted
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- Root cause anaylsis
- Risk assessment
-
(and 1 more)
Tagged with:
-
Event
Root Cause Analysis: 2 day masterclass
Patient Safety Learning posted an event in Community Calendar
untilThis intensive two day masterclass will provide Root Cause Analysis training in line with the 2019 Patient Safety Strategy and subsequent guidance. The course will offer a practical guide to conducting RCA with a focus on systems-based patient safety investigation as proposed within the latest guidance released by NHS England and NHS Improvement. The course provides insights into how RCA is evolving and gives detailed information on what standards RCA investigations are expected to reach following the detailed recent reviews of patient safety work across the NHS and healthcare. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/root-cause-analysis-2-day-masterclass or email: kate@hc-uk.org.uk. hub members receive 20% discount. Email info@pslhub.org for discount code. -
Event
Root Cause Analysis: 1 day masterclass
Patient Safety Learning posted an event in Community Calendar
This intensive masterclass will provide in-house Root Cause Analysis training in line with The NHS Patient Safety Strategy (July 2019). 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. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/root-cause-analysis-1-day-masterclass or email kate@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for discount code. -
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
- Posted
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- Patient safety incident
- Canada
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(and 2 more)
Tagged with:
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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
- Posted
-
- Patient safety incident
- Risk assessment
-
(and 2 more)
Tagged with:
-
Event
Root Cause Analysis: 2 day masterclass
Patient Safety Learning posted an event in Community Calendar
untilThis two day intensive masterclass will provide Root Cause Analysis Training in line with the July 2019 Patient Safety Strategy. This intensive two-day masterclass will provide Root Cause Analysis training in line with the 2019 Patient Safety Strategy and subsequent guidance. The course will offer a practical guide to conducting RCA with a focus on systems-based patient safety investigation as proposed within the latest guidance released by NHS England and NHS Improvement. The course provides insights into how RCA is evolving and gives detailed information on what standards RCA investigations are expected to reach following the detailed recent reviews of patient safety work across the NHS and healthcare. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/root-cause-analysis-2-day-masterclass or email kate@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for further information.- Posted
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- Root cause anaylsis
- Training
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(and 2 more)
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Content ArticleThis paper, published in Applied Ergonomics, looks at how those in healthcare might select which technique to use to predict error. The author concludes: "there is a lack of practical experiences described in the literature to conclusively define a technique for selection and a need for a dedicated research in this area to make it accessible for healthcare and other novice users".
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- Root cause anaylsis
- Staff support
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