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Showing results for tags 'Root cause anaylsis'.
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Content ArticleMedicine has traditionally been one of the most cognitively demanding occupations. This paper from Bob Baron, President and Chief Consultant of The Aviation Consulting Group, discusses the limitations of human performance in the hospital environment. Human factors models are presented and used as an anchor for a randomly selected case study involving a potentially lethal medication error. The case study’s root cause analysis showed five distinct factors that were causal to the error. The human factors models, in conjunction with an overview of basic human cognition, provide the reader with the tools to understand all five findings of the case study. This paper will provide a foundation for improving medical safety by creating an awareness of the factors that influence errors in medical procedures.
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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. For further information and to book your place or email kate@hc-uk.org.uk hub members receive 20% discount code. Email info@pslhub.org -
Event
Root Cause Analysis: 1 day masterclass
Patient Safety Learning 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. 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’. Further information and to book your place visit or email: kate@hc-uk.org.uk hub members receive a 20% discount. Email: info@pslhub.org -
Event
Root Cause Analysis: 1 day masterclass
Patient Safety Learning 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. 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’. Further information and to book your place visit or email: kate@hc-uk.org.uk hub members receive a 20% discount. Email: info@pslhub.org -
Event
Root Cause Analysis: 1 day masterclass
Patient Safety Learning 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. 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’. Further information and to book your place visit or email: kate@hc-uk.org.uk hub members receive a 20% discount. Email: info@pslhub.org -
Content ArticleRoot cause analysis (RCA) is a process widely used by health professionals to learn how and why errors occurred, but there have been inconsistencies in the success of these initiatives.
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Event
Root Cause Analysis: 1 Day Masterclass
Patient Safety Learning 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. 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’. Further information and registration to book your place or email: kate@hc-uk.org.uk hub members receive 10% discount. Email info@pslhub.org -
Content Article
Patient referrals and waiting lists: A ticking time bomb
Jerome P posted an article in By health and care staff
Jerome, a patient safety manager, discusses the impact the pandemic is having on patient referrals and waiting lists, and the subsequent increases in serious incidents and never events that will arise. With an already overstretched and exhausted workforce, how will these be investigated, how will this be managed? Jerome urges NHS England to give guidance.- Posted
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Content ArticleBioPhorum has developed a risk-based deviation management system (DMS). 13 member companies have implemented this approach, and summary data from these companies shows improved quality performance plus an average time saving of 22,200 work hours per site per year, which is equivalent to a $888k cost saving. An effective deviation management process is one that identifies and removes risk from processes using root cause analysis (RCA) principles and a corrective and preventive action (CAPA) programme. The current model used by many biopharmaceutical companies considers all deviations or events are equal and require a 30-day closure, known as the ‘30-day rule’1. Treating all events as equal and following the ‘30-day rule’ drives an inefficient process and wasteful behaviours. This guide outlines the work of the BioPhorum DMS Workstream in defining and creating a simplified and effective risk-based deviation management system with advanced RCA methodologies, and a track-and-trending process of low-risk events. It includes everything required to build a risk-based approach to DMS, including the business case for change, the new process, risk-based tools, and a detailed sharing of post-implementation benefit.
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Event
Root Cause Analysis: 2 Day Masterclass
Patient Safety Learning posted an event in Community Calendar
untilThe 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 and 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 in RCA skills. For further information and to book your place or email: kate@hc-uk.org.uk hub members can receive a 10% discount. Email: info@pslhub.org -
Event
Root Cause Analysis: 1 Day Masterclass
Patient Safety Learning 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. 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. For further information and to book or email: kate@hc-uk.org.uk hub members can receive a 10% discount. Email: info@pslhub.org -
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?
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Content ArticleThis document defines the investigation framework in the event of a patient safety Serous Incident (SI) related to NHS Wales Informatics Service (NWIS) delivered or supported services, which affects one or more health body in Wales.
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Event
Root Cause Analysis: 1 Day Masterclass
Sam posted an event in Community Calendar
This 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. Further information and book your place or email kate@hc-uk.org.uk hub members receive 10% discount. Email info@pslhub.org for code -
EventThe best way to solve problems is to identify their root causes. With RCA, you’re equipped to build a learning culture, help identify frequent modes of failure and take action to develop new policies or training to prevent incidents from happening in the future. Incorporate and blend taxonomies to support your organisation’s key initiatives. Increase efficiency by initiating a root cause analysis from multiple existing files in RL6. Leverage dashboards and reports to learn and drive safety improvements. Utilize the Joint Commission and RCA2 framework to uncover the root cause(s) and opportunities for risk reduction. Register
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EventStreamline your policy management workflow in the cloud with PolicyStat. From single hospitals to multi-facility organisations, all your policies and procedures are in one easily accessible library and always kept current. Efficiently organise and govern policies, procedures and related documentation . Stay compliant and audit ready to avoid penalties and drive better outcomes. Optimise policy workflows and change management to improve performance. Align culture, process and people for better document control and regulatory compliance. Register
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EventOptimise your time with a centralised, secured data system that helps you remain compliant with organisational standards and supports your safety and quality initiatives Implement tailored access to provide enhanced security and make reviews easier for committees, reviewers and subjects. Maintain reviewers’ complete confidentiality from staff members and other reviewers. Seamlessly integrate Peer Review with other RL6 Modules including Risk, Feedback, Claims and Root Cause Analysis to optimise communication and monitor adherence to policies Quickly and easily review provider performance and care quality from custom reporting and dashboards . Register
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Content ArticleElderly people in care homes in Cornwall were abused and neglected while failings led to reports of concerns not being investigated, a new Safeguarding Adults Review has found. The Morleigh Group, which operated seven homes in Cornwall and has since shut down, was exposed in a BBC Panorama investigation in 2016. A new Safeguarding Adults Review which was commissioned as a result of the TV show has been published making a number of recommendations to all agencies which were involved in the case. The review was completed in April 2019 but has only just been made public - Rob Rotchell, Cornwall Council Cabinet member for adult social care said that this was due to the number of agencies being involved.
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Content ArticleThis short blog from Jerome, a patient safety manager, gives a brief description of root cause analysis and asks why the NHS spends so much time generating root cause analysis reports rather than focussing on what changes should happen afterwards to current systems and processes.
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Content ArticleDo you ever see someone trapped into making a human error? Bad human engineering caused an error likely situation. Perhaps there was a precursor to the error – somethings that could be recognised?
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Content Article“Failure to rescue” (FTR) is the failure to prevent a death resulting from a complication of medical care or from a complication of underlying illness or surgery. There is a growing body of evidence that identifies causes and interventions that may improve institutional FTR rates. Why do patients “fail to rescue” after complications in hospital? What clinically relevant interventions have been shown to improve organisational fail to rescue rates? Can successful rescue methods be classified into a simple strategy?
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Content ArticleCause and effect is a diagram-based technique that helps you identify all of the likely causes of the problems you're facing.
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Content Article
Failure - is it a matter of when?
Claire Cox posted an article in Miscellaneous
'When problems occur we hunt for a single root cause, that one broken piece or person to hold accountable. Our analyses of complex system breakdowns remains linear, componential and reductive.' This is evident in healthcare. Barry O’Reilly is a business advisor, entrepreneur and author who has pioneered the intersection of business model innovation, product development, organisational design and culture transformation. In this blog he discusses the 'drift into failure', i.e. we had the warning signs but accepted them as the norm. -
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. hub members can receive a 10% discount with code hcuk10psl. Further information and registration -
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. hub members can receive a 10% discount with code hcuk10psl. Further information and registration
