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Showing results for tags 'Root cause anaylsis'.
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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. 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. -
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. -
EventuntilThe Patient Safety Authority (PSA) invites you to attend a programme on root cause analysis (RCA). This programme is open to hospitals and ambulatory surgical facilities (ASFs). 'Getting to the "root” of the problem: Conducting an RCA' is for those who are new to the RCA process or would like a refresher. It will provide introductory-level content within the framework of the PSA RCA Investigation Tool. Following this program, attendees should be able to: 1. Define Root Cause Analysis (RCA) 2. Discuss when an RCA is appropriate 3. Identify steps involved in the RCA process Those who should consider attending this program are: Patient Safety Officers Risk Managers Quality Directors Human Resource Directors Executive Leaders Physicians Educators Clinical Leaders. Register
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Event
Root Cause Analysis: 1 day masterclass
Patient Safety Learning posted an event in Community Calendar
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’. For further information and to book your place visit www.healthcareconferencesuk.co.uk/conferences-masterclasses/root-cause-analysis-1-day-masterclass or email kate@hc-uk.org.uk hub members receive 20% discount. Email info@pslhub.org for discount code. -
Content ArticleHealth systems currently present a great degree of complexity, which provides risks to patients related to healthcare, and the possibility of incidents with or without harm. Patient safety culture highlights the need to investigate, analyse, and mitigate incidents to reduce risks to the patient. Medication errors have a high potential to do harm in paediatric hospital routines and most of them are preventable. The objective of this study was to describe a severe drug-related adverse event and present the root cause analysis and implemented improvements.
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- Medication
- Adminstering medication
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EventWhen accidents occur in healthcare, providers and health systems have an urgent responsibility to respond to prevent future harm. In this online course from the Institute for Healthcare Improvement (IHI), you'll learn to improve your event review process with a unique approach — endorsed by leaders in patient safety across the United States and abroad — that expands upon traditional root cause analysis. Moving swiftly after a safety incident occurs, you'll learn to establish a small team to conduct interviews, develop a flowchart, and pinpoint vulnerabilities in your system: poor equipment design, inadequate training, or insufficient resources. Most importantly, by the end of the course, you'll gain tools and strategies to address these vulnerabilities with sustainable actions that really work to prevent future harm. This is the focus of Root Cause Analyses and Actions — or RCA2. During this online course, you will: Explore the type of culture it takes to support RCA2. Learn to prioritize events for RCA2 review. Assemble an effective RCA2 team. Explore strategies to engage patients in the RCA2 process. Gain tools and techniques for conducting interviews after an adverse event occurs. Use flowcharting after an adverse event to understand what happened and why. Learn to identify actions that will protect patients and staff from future harm. Apply goal-setting and measurement techniques to facilitate sustained improvement. Implement approaches for evaluating the success of RCA2. Explore creative possibilities for future applications of RCA2.
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Content ArticleThe fishbone diagram is a widely-used patient safety tool that helps to facilitate root cause analysis discussions. The authors of this article in the journal Diagnosis expanded this tool to reflect how both systems errors and individual cognitive errors contribute to diagnostic errors. They describe how two medical centres in the US have applied this modified fishbone diagram to approach diagnostic errors in a way that better meets their patient safety and educational needs.
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- Diagnosis
- Diagnostic error
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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. To register go to 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 a discount code. -
Event
Root Cause Analysis: 1 day masterclass
Patient Safety Learning posted an event in Community Calendar
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. The course 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’. 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. We are pleased to offer hub members a 20% discount. Please email info@pslhub.org for the code.- Posted
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- Root cause anaylsis
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Event
Root Cause Analysis: 1 day masterclass
Patient Safety Learning posted an event in Community Calendar
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. The course 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’. 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. We are pleased to offer hub members a 20% discount. Please email info@pslhub.org for the 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 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 discount code -
Content ArticleThe experience feedback committee (EFC) is a tool designed to involve medical teams in patient safety management, through root cause analysis within the team. This study in the Journal of Patient Safety aimed to establish whether patient safety culture, as measured by the Hospital Survey on Patient Safety Culture (HSOPS), differed regarding care provider involvement in EFC activities. The authors found that participation in EFC activities was associated with higher patient safety culture scores, suggesting that root cause analysis in the team’s routine may improve patient safety culture.
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- Root cause anaylsis
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Content ArticleIn this blog, Jessica Behrhorst, Senior Director for Patient Safety at the Institute for Healthcare Improvement (IHI), discusses challenges staff face in creating a safety culture, such as fear of negative consequences and thinking they will not be taken seriously. She highlights the importance of acknowledging these fears and building positive group norms in order to engage staff. She also highlights the role of root cause analysis in addressing fears about speaking up.
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- Speaking up
- Safety culture
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Content Article'Patient Safety: The PROACT® Root Cause Analysis Approach' addresses the proactive methodologies and organisational paradigms that must change in order to support and sustain activities that promote patient safety. Written by reliability expert Robert J. Latino, this book provides a perspective on patient care from outside the health industry and culture. It teaches a proven approach that measures its effectiveness based on patient safety results, rather than compliance, and demonstrates the Return-On-Investment for using root cause analysis to reduce and/or eliminate undesirable outcomes. Addressing the contribution of human error to physical consequences, Latino explores ways to identify conditions that are more prone to result in human error.
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- Technology
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EventObjectives: Describe the steps involved in conducting RCA of an error. List the tools that can be used during the RCA process. Identify who should be included on a debriefing team and what the ground rules are that will allow a debriefing meeting to be most effective. Register
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- Root cause anaylsis
- Saudi Arabia
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Event
Root Cause Analysis: One 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’. 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 can receive a 20% discount. Email info@pslhub.org discount code. -
Content ArticleAn examination of how humans interact with their environments and each other led this team to question one of its long-standing medication safety practices and change how they work.
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- Human factors
- Paediatrics
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Event
Root Cause Analysis: 1 day masterclass
Patient Safety Learning posted an event in Community Calendar
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 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’. 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 infor@pslhub.org for discount code. -
Event
Root Cause Analysis: 1 day masterclass
Patient Safety Learning posted an event in Community Calendar
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 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’. 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 infor@pslhub.org for discount code. -
Content ArticleTwo years ago, a patient safety incident at North Bristol Trust led to the introduction of Swarm – a step change in how the trust responds to safety incidents. Swarm is a form of safety incident huddle that takes place as close as possible in time and place to the incident, allows blame-free investigation and leads to prompt action. This article describes how Swarm works, its advantages over root cause analysis, and how it is being embedded in the safety culture of North Bristol Trust.
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- Patient safety incident
- Investigation
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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. 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. 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 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. -
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. -
Content ArticleAn examination of how humans interact with their environments and each other led a team at Spectrum Health Helen DeVos Children’s Hospital in Grand Rapids, Michigan, USA, to question one of its long-standing medication safety practices and change how they work.
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- Human factors
- Root cause anaylsis
- (and 4 more)
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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- Posted
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- Root cause anaylsis
- Investigation
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