Search the hub
Showing results for tags 'Root cause anaylsis'.
-
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
-
- Patient safety incident
- Canada
-
(and 2 more)
Tagged with:
-
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
-
- Root cause anaylsis
- Training
-
(and 2 more)
Tagged with:
-
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
-
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. -
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.
-
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. -
Community PostI am currently working to develop a new process for the investigation of incidents related to digital healthcare, something which clearly sits outside of the usual framework or process of investigating traditional patient safety incidents. I would be grateful for opportunities to discuss and share experiences and ideas with others. If you have already investigated these sort of incidents what sort of approach did you utilise and have you reviewed it post event in respect of effectiveness. @Keith Bates Clive has suggested it would be beneficial for us to discuss?
- Posted
- 2 replies
-
2
-
- Digital health
- Electronic Health Record
- (and 6 more)
-
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
- Posted
-
- Health inequalities
- Health Disparities
- (and 3 more)
-
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
-
- Patient harmed
- Patient / family involvement
- (and 13 more)
-
Content ArticleWales' national policy on patient safety incident reporting and management.
- Posted
- 1 comment
-
1
-
- Patient safety incident
- Risk management
- (and 14 more)
-
Community Post
The Patient Safety Incident Response Framework
Jon Holt posted a topic in Investigations, risk management and legal issues
- Near miss
- Never event
- (and 7 more)
Hi The new Patient Safety Incident Response Framework is due for publication this month for early adopters and as 'introductory guidance' for everyone else: https://improvement.nhs.uk/resources/about-new-patient-safety-incident-response-framework/ I wondered if there is anyone who is involved in an organisation that is an early adopter who can share what has happened so far and also would be willing to share any local learning as the new framework is implemented? Also, more generally wondered if anyone has any initial comments on the proposals which were mentioned in the NHS patient safety strategy and any things in particular which they think will bring benefit or could represent significant challenges or issues?- Posted
- 10 replies
-
- Near miss
- Never event
- (and 7 more)
-
Community PostDear hub members We've a request to help from New South Wales. They and their RLDatix colleagues request: The public healthcare system in New South Wales (NSW), Australia is changing how we investigate health care incidents. We are aiming to add to our armoury of investigation methods for serious clinical incidents and would love to hear your suggestions. Like many health care settings worldwide, in NSW we have solely used Root Cause Analysis (RCA) for over 15 years. We are looking for alternate investigation methods to complement RCA. So we are putting the call out … Are there other serious incident investigation methods (other than RCAs) you would recommend? What’s been your experience with introducing and/or using these methods? Do you have learnings, data or resources that you could share? Do you have policy or procedure documents about specific methods? Any journal articles – health care or otherwise – that are must-reads? We've many resources on investigations on the hub and recent thinking in the UK and internationally that might be of value including: UK Parliamentary report - Investigating clinical incidents in the NHS and from that the creation of A Healthcare Safety Investigation Branch applying a wide range of methodologies in national learning investigations informed by ergonomics and human factors UK's NHS Improvement recent engagement on a new Serious Incident Framework (due to piloted in early 2020) Dr Helen Higham work with the AHSN team in Oxford to improve the quality of incident investigations Patient engagement in investigations Lessons to be learned from Inquiries into unsafe care and reflections on the quality of investigations Insights by leading investigators and resources written specifically for us by inclusion our Expert Topic Lead @MartinL Do check these out in this section of the hub https://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/ Please add to this knowledge and give us your reflections. We'd be happy to start up specific discussions on topics of interest. Thank you all, Helen
- Posted
- 13 replies
-
- Investigation
- Patient safety incident
- (and 3 more)
-
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
-
- Root cause anaylsis
- Training
-
(and 1 more)
Tagged with:
-
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
-
- Root cause anaylsis
- Training
-
(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 a 20% discount. Email info@pslhub.org for discount code -
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
- Posted
-
- Root cause anaylsis
- Saudi Arabia
- (and 1 more)
-
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. -
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. -
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.