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Found 47 results
  1. Content Article
    Over the last five years, teams at Spectrum Health Helen DeVos Children’s Hospital in Grand Rapids, Michigan, had completed at least four different improvement projects focused on increasing adherence to the independent double check (IDC) process. An IDC is when two registered nurses independently check a medication to ensure it is correct prior to administering it to the patient. Like other institutions, the hospital did not require this process for all medications but did require it for a select group of medications considered higher risk if given in incorrect doses, routes or times.
  2. Content Article
    'Dr Lucy Johnstone, one of the lead authors of the Power Threat Meaning Framework, said: "The Power Threat Meaning Framework can be used as a way of helping people to create more hopeful narratives or stories about their lives and the difficulties they have faced or are still facing, instead of seeing themselves as blameworthy, weak, deficient or ‘mentally ill’. It highlights and clarifies the links between wider social factors such as poverty, discrimination and inequality, along with traumas such as abuse and violence, and the resulting emotional distress or troubled behaviour, whet
  3. Event
    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 fa
  4. Event
    until
    This 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 investigat
  5. Event
    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 cou
  6. Event
    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 cou
  7. Event
    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 cou
  8. Content Article
    With a grant from The Doctors Company Foundation, the National Patient Safety Foundation convened a panel of subject matter experts and stakeholders to examine best practices around RCAs and develop guidelines to help health professionals standardize the process and improve the way they investigate medical errors, adverse events, and near misses. To improve the effectiveness and utility of these efforts, the Institute of Healthcare Improvement have concentrated on the ultimate objective: preventing future harm. Prevention requires actions to be taken, and so they have renamed the process Root
  9. Event
    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 cou
  10. Content Article
    It’s been a really difficult time for all of us this past year. When I say ‘we’, I mean every single person on the planet. I am yet to find anyone who hasn’t had to deal with stress, mental health problems, anxiety, illness, disappointment or bereavement of some nature over the past year. Collectively, we are all going to need a period to heal. I fear that the healthcare system will have no time to heal and that we are only on the tip of what more there is to come. Not only has the healthcare system had to deal with a pandemic, we have had to deal with the consequences from that. The
  11. 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 effo
  12. Event
    until
    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 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%
  13. 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
  14. Community Post
    I 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?
  15. 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.
  16. 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
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