Jump to content

Search the hub

Showing results for tags 'Root cause anaylsis'.


More search options

  • Search By Tags

    Start to type the tag you want to use, then select from the list.

  • Search By Author

Content Type


Forums

  • All
    • Commissioning, service provision and innovation in health and care
    • Coronavirus (COVID-19)
    • Culture
    • Improving patient safety
    • Investigations, risk management and legal issues
    • Leadership for patient safety
    • Organisations linked to patient safety (UK and beyond)
    • Patient engagement
    • Patient safety in health and care
    • Patient Safety Learning
    • Professionalising patient safety
    • Research, data and insight
    • Miscellaneous

Categories

  • Commissioning, service provision and innovation in health and care
    • Commissioning and funding patient safety
    • Digital health and care service provision
    • Health records and plans
    • Innovation programmes in health and care
  • Coronavirus (COVID-19)
    • Blogs
    • Data, research and statistics
    • Frontline insights during the pandemic
    • Good practice and useful resources
    • Guidance
    • Mental health
    • Exit strategies
    • Patient recovery
  • Culture
    • Bullying and fear
    • Good practice
    • Safety culture programmes
    • Second victim
    • Speak Up Guardians
    • Whistle blowing
  • Improving patient safety
    • Design for safety
    • Disasters averted/near misses
    • Equipment and facilities
    • Human factors (improving human performance in care delivery)
    • Improving systems of care
    • Implementation of improvements
    • Safety stories
    • Stories from the front line
    • Workforce and resources
  • Investigations, risk management and legal issues
    • Investigations and complaints
    • Risk management and legal issues
  • Leadership for patient safety
  • Organisations linked to patient safety (UK and beyond)
  • Patient engagement
  • Patient safety in health and care
  • Patient Safety Learning
  • Professionalising patient safety
  • Research, data and insight
  • Miscellaneous

News

  • News

Find results in...

Find results that contain...


Date Created

  • Start
    End

Last updated

  • Start
    End

Filter by number of...

Joined

  • Start

    End


Group


First name


Last name


Country


About me


Organisation


Role

Found 20 results
  1. 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.
  2. 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.
  3. 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.
  4. 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?
  5. 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.
  6. News Article
    The Independent Inquiry into the issues raised by Paterson is yet another missed opportunity to tackle the systemic patient safety risks which lie at the heart of the private hospital business model, says David Rowland from the Centre for Health and the Public Interest in a recent BMJ Opinion article. Although the Inquiry provided an important opportunity for the hundreds of patients affected to bear witness to the pain and harm inflicted upon them it fundamentally failed as an exercise in root cause analysis. None of the “learning points” in the final report touch on the financial incentives which may have led Paterson to deliberately over treat patients. Nor do they cover the business reasons which might encourage a private hospital’s management not to look too closely. He suggests that the Inquiry report threw the responsibility for managing patient safety risks back to the patients themselves in two of its main recommendations but that it should be for the healthcare provider first and foremost to ensure that the professions that they employ are safe, competent and properly supervised, and for this form of assurance to be underpinned by a well-functioning system of licensing and revalidation by national regulatory bodies. Read full story Source: BMJ Opinion, 20 February 2020
  7. Community Post
    Dear 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
  8. 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.
  9. Content Article
    Five root causes for accidental sharing of pens were identified: knowledge gaps and practice variation labels insulin storage and removal process information technology issues including those related to barcode medication administration and the electronic health record insulin administration workflow. Four major interventions to address the root causes were developed and tested: patient-specific bar coding on insulin pens redesign of labels systematic removal of discharged patients’ medications ongoing staff education.
×