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Found 30 results
  1. Content Article
    Problems related to the care home and the company were known well before the Panorama expose in 2016. When the Panorama programme was aired it resulted in immediate closure of one home and all the homes which were operated by Morleigh being transferred to new operators. The Review includes reports of abuse against residents; residents being left to lie in wet urine-soaked bedsheets; concerns from relatives about their loved ones being neglected; reports of there being insufficient food for residents, no hot water and no heating; claims that dozens of residents were sharing one bathroom. Here's a summary of the report's findings: More than 100 residents had concerns raised more than once. More than 200 safeguarding alerts were made for individuals but only 16 went through to an individual adult safeguarding conference. More than 80 whistleblower or similar reports were made concerning issues that put residents at risk. 44 inspections were undertaken at Morleigh Group homes in the three-year period, the vast majority identifying breaches. There was a period of at least 12 months when four of the homes had no registered manager in place. During the three-year period reviewed the police received 130 reports relating to the care homes. A spokesperson for Cornwall Council said: “We have different procedures and policies in place and have invested time, money and staffing into making sure that we can respond better when concerns are raised.'' “One of the problems was that all the partners had their own policies and procedures but they weren’t integrated. That is probably one of the key issues that we have now addressed.” “The assessment is so different now and the organisations are working much more closely that it reduces the risk dramatically.'' This is an important and long-awaited review. This situation echoes other care home scandals across the UK. I urge everyone to read the full report and reflect on the real root causes of the problem, which I believe go well beyond failings in inter-agency policies and communication. What would your action plan be? How would you monitor it?
  2. Event
    The 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
  3. Event
    Streamline 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
  4. Event
    Optimise 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
  5. Content Article
    I believe all clinicians should read this latest report. There is so much to be learned and so many changes in clinical practice that can be made right away. Since 2018, I have been teaching using Oliver's tragic story to promote reflection on best practice in prescribing and in implementing the Mental Capacity Act. I could write a lot here; however, I believe this is a report all clinicians, and especially all prescribers, need to read in full. A summary of how I see this (or indeed how any individual sees it) it will not be adequate.
  6. Content Article
    What is root cause analysis? Root cause analysis (RCA) is a structured method used to analyse serious adverse events. Initially developed to analyse industrial accidents, RCA is now widely deployed as an error analysis tool in healthcare. The RCA approach is the current methodology to investigate why and how serious incidents have happened in healthcare and to assure the Trust, Clinical Commissioning Group (CCG) and the patient/family that lessons have been learned and that the incident will not happen again. This methodology is soon to change next year as set out in the new Patient Safety Incident Response Framework. What happens to the report? Once written, the RCA report will be sent to the CCG, other outside bodies and the patient/family, alongside an action plan on how practices will change. What type of incident is RCA used for? Many Trusts will perform an RCA on incidents which are deemed to have greater learning for the Trust despite the degree of harm, moderate harm and above, and never events. Most Trusts use a modified RCA for ‘local’ investigations – these incidents may include pressure damage, falls and medication errors. What is the process? The current process of undertaking and processing a serious incident is laid out below. This is taken from the NHS Serious Incident Framework. Many Trusts will provide RCA training to anyone undertaking the lead role in an investigation – this could be a patient safety lead or a clinician. How long does it take to complete an RCA? This can depend on the experience of the investigator, the capacity of the department involved to collect statements, a timeline and information. If the incident has been declared to the CCG, the report will need to be completed within 60 days. A local RCA should take no longer than 4 weeks. How many RCAs are completed each year in the UK? During 2018 there were nearly 62,500 incidents that were reported as moderate harm or above. The majority of these would require an RCA. This figure does not include incidents that were not reported on to the Strategic Executive Information System (StEIS) but were investigated using the root cause analysis locally. Currently, patient safety teams up and down the country are drowning in writing RCA reports. We are caught up in a process of investigating harm that has already happened. Hours, days, months are spent having meetings mulling over the RCA. Looking at timelines, thinking of why the incident happened and whether there was any way for it to have been prevented. The cost of undertaking an RCA must be in the thousands of pounds. The team often includes the patient’s consultant, head of nursing, governance leads, patient safety managers and clinical staff. This group may meet up at several different occasions to make sure that all facts are correct and that the RCA is written well and meet a standard that the CCG will accept. Multiple drafts are written before submitting the final report. Action plans are found at the bottom of the RCA – once the root causes have been found, that is when the actions can be formulated. These actions will need to be carried out in the department/area where the incident took place or across the Trust if it was a system failure. Once written and signed off by the Trust and the CCG – the RCA is complete. What happens next? The end of the RCA should be the beginning of either a quality improvement initiative, a new policy, a change in practice or change in process. This part of the process is often poor – ‘reminding staff’, ‘education’ and ‘reflection’, assuming it must be human error and must be ‘fixed’ by telling people how to do it better. There is little training in setting appropriate actions or a centralised place to evidence that the action is now imbedded. The Care Quality Commission (CQC) can call on these actions and the evidence of these actions at any time. At present there is not a robust, standardised approach across the NHS to gather evidence that actions have been put in place post incident. One of the reasons for this is a lack of capacity and capability due to the industry we have made of writing the RCA and lack of quality improvement training or time provided to all staff throughout the NHS. Final words Have we forgotten the purpose of our role within patient safety? Figuring out what went wrong systemically is only one part of our role; however, assuring the family and patient that we have put new systems in place and that we are striving for this incident to never happen again is equally, if not more, important – so why is there not a standard process/industry for this? If we focussed more on the prevention we could get off the hamster wheel of investigating recurrent harm. It is hoped that the new serious incident framework will address this issue and allow us the time and the capability to put in measures to stop recurrent harm happening to patients and the public. What are your solutions to action plans and gathering the evidence for these plans? Have you a system that is easy to keep track of RCA reports and follow up? I would also be interested in the patient/public view of investigation reports and whether this type of approach is what they want?
  7. Community Post
    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?
  8. Event
    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
  9. Event
    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
  10. Content Article
    Burke et al. carried out a systematic review. All studies that explored an intervention to improve failure to rescue in the adult population were considered. They found that complications occur consistently within healthcare organisations and organisations vary in their ability to manage such events. Failure to rescue is a measure of institutional competence in this context. The authors propose “The 3 Rs of Failure to Rescue” of recognise, relay and react, and hope that this serves as a valuable framework for understanding the phases where failure of patient salvage may occur. Future efforts at mitigating the differences in outcome from complication management between units may benefit from incorporating this proposed framework into institutional quality improvement.
  11. Content Article
    Why use this tool? To allow a team to explore the possible reasons, root causes and possible solutions for a problem To visually represent the reasons, root causes and possible solutions for a problem To help identify change ideas and develop an improvement plan To enable team to focus on content of the problem, not on the history or differing personal interests.
  12. Content Article
    This qualification is for anyone who wants to carry out incident investigations effectively. Employers, supervisors, SHE champions, union and safety representatives will benefit. Attending the course will enable you to: Independently investigate simple incidents. Gather evidence including conducting witness interviews. Produce an action plan to prevent a recurrence of an incident. Contribute to team investigations for large scale incidents Positively impact the safety culture in your organisation.
  13. Content Article
    Key learning points Education and training of healthcare workers Equip the workforce with the fundamental knowledge and skills of human factors/ergonomics. Support, promote and embed the discipline in the practitioner’s professional training and development. Empower participation in human factor/ergonomic initiatives. Draw on existing expertise. Organisational commitment Comprehensive, resilient, proactive patient safety programme. Safety culture (not punitive to individual). Risk management system. Programme evaluation, meaningful and informative indicators, continuous learning and improvement.
  14. Content Article
    This framework provides staff and medical staff with: a standardised methodology including a common analysis language; and standardised analysis tools for reviewing clinical adverse events and close calls. There are three methodologies described within this handbook that can be used to review clinical Adverse Events. These methodologies are designed to suit the scope of a clinical adverse event or multiple clinical adverse events, and provide flexibility for the user. The Concise method is commonly used for a succinct review of close calls or clinical adverse events that result in no, low, or moderate harm to the patient or may focus on a new event for which a Comprehensive analysis was recently completed. The concise method is generally used for reviews conducted by one or two individuals. The Comprehensive method is used for a thorough review of a single clinical adverse event and involves a team approach. The Aggregate method involves a thorough review of multiple clinical adverse events and/or quality assurance reviews. This method is resource intensive and involves a team approach.
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