Never Events LISA Matt Provost
|
|
|
- Morris Benson
- 5 years ago
- Views:
Transcription
1 Never Events LISA 2017 Matt Provost
2 Yelp s Mission Connecting people with great local businesses.
3 History of the NHS World s first universal health care system - June 1948 Clement Attlee's Labour government 3 founding core principles Meet the needs of everyone Free at the point of delivery Based on clinical need, not ability to pay Serves 64.6 million people in the UK 1 million patients every 36 hours 5th largest employer in world (2015) - 1.7m staff
4
5
6 NHS Serious Incident Framework Unexpected or avoidable death of one or more people. This includes: suicide/self-inflicted death; and homicide by a person in receipt of mental health care within the recent past; Unexpected or avoidable injury to one or more people that has resulted in serious harm; Unexpected or avoidable injury to one or more people that requires further treatment by a healthcare professional in order to prevent: the death of the service user; or serious harm; Actual or alleged abuse; sexual abuse, physical or psychological ill treatment, or acts of omission which constitute neglect, exploitation, financial or material abuse, discriminative and organisational abuse, self neglect, domestic abuse, human trafficking and modern day slavery where: healthcare did not take appropriate action/intervention to safeguard against such abuse occurring; or where abuse occurred during the provision of NHS-funded care.
7
8 Never Events Never Events arise from the failure of strong systemic protective barriers which can be defined as successful, reliable and comprehensive safeguards or remedies e.g. a uniquely designed connector to prevent administration of a medicine via the incorrect route. Serious Incident Framework 2015
9 Never Event Criteria Wholly preventable Potential to cause serious patient harm or death Has occurred in the past, risk of recurrence remains Easily recognised and clearly defined
10 Never Event Criteria They are wholly preventable, where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level, and should have been implemented by all healthcare providers.
11 Systemic Protective Barriers Physical barriers (e.g. special equipment that makes it impossible to connect medications via the wrong route) Time and place barriers (e.g. withdrawal of concentrated medication from settings to prevent accidental selection) or systems of double or triple checking only where supported by visual or computerised warnings, standardised procedures, or memory/communication aids.
12
13 Systemic Protective Barriers As all human action is vulnerable to human error, particularly where there is a risk of staff becoming overloaded, processes that rely solely on one staff member checking the actions of another or referring to written policies are not strong barriers. Revised Never Events Policy and Framework 2015
14 Never Event Criteria Each Never Event type has the potential to cause serious patient harm or death. However, serious harm or death is not required to have happened as a result of a specific incident occurrence for that incident to be categorised as a Never Event.
15 Dropped Object Prevention Scheme Recommended Practice, 2017
16
17 Yelp DAR Levels DAR1 - The site is broken, or we re losing lots of money The site is hard down to some or all users We are serving Darwins or HAProxy error pages DAR2 - Users are having a bad experience, or we re losing some money Slow timings (99ths, 50ths) on any site (>2x normal levels) DAR3 - This is serious, but not visible to users or affecting revenue Code cannot get to production
18 Never Event Criteria There is evidence that the category of Never Event has occurred in the past, for example through reports to the National Reporting and Learning System (NRLS), and a risk of recurrence remains.
19 Never Event Criteria Occurrence of the Never Event is easily recognised and clearly defined this requirement helps minimise disputes around classification, and ensures focus on learning and improving patient safety.
20 Never Event Criteria Wholly preventable Potential to cause serious patient harm or death Has occurred in the past, risk of recurrence remains Easily recognised and clearly defined
21 NHS Never Events List 2015/16 Surgical Medication Mental Health General
22 NHS Never Events List 2015/16 Surgical Wrong site surgery Wrong implant/prosthesis Retained foreign object post-procedure
23 NHS Never Events List 2015/16 Medication Mis selection of a strong potassium containing solution Wrong route administration of medication Overdose of Insulin due to abbreviations or incorrect device Overdose of methotrexate for non-cancer treatment Mis selection of high strength midazolam during conscious sedation
24 NHS Never Events List 2015/16 Mental Health Failure to install functional collapsible shower or curtain rails
25 NHS Never Events List 2015/16 General Falls from poorly restricted windows Chest or neck entrapment in bedrails Transfusion or transplantation of ABO-incompatible blood components or organs Misplaced naso- or oro-gastric tubes Scalding of patients
26 NHS Never Events
27 NHS Never Events * Wrong site surgery 178 Retained foreign object post procedure 109 Wrong implant / prosthesis 49 Wrong route administration of medication 40 Misplaced naso or oro gastric tubes 26 Overdose of insulin due to abbreviations or incorrect device 6 Overdose of methotrexate for non cancer treatment 5 Chest or neck entrapment in bedrails 3 Falls from poorly restricted windows 3 Failure to install functional collapsible shower or curtain rails 2 Scalding of patients 1 Mis-selection of a strong potassium containing solution 1 Transfusion or transplantation of ABO incompatible blood components or organs *Provisional
28 Wrong Site Surgery
29
30
31
32
33
34
35
36
37 Retained Foreign Object Post-Procedure
38
39 Never Events per Million Procedures
40
41 Serious Incident Management Process Inform organisational leaders Inform patient/family/carer Report on National Reporting and Learning System Root Cause Analysis (RCA) Review learning and implementation plan Public board meeting Share appropriate learning Include in annual reports and quality accounts
42 Post Never Event Timeline Working Days Inform organisational leaders Inform patient/family/carer 2 Report on NRLS 3 Root Cause Analysis 60 Review learning and implementation plan 20* * Calendar Days
43 NTSB
44 Checklist Define Serious Incidents Timeboxed Serious Incident Management Process RCA/Postmortem Collect preventable incidents Put Systemic Protective Barriers in place Investigate near misses
45 We're Hiring!
46 engineeringblog.yelp.com github.com/yelp
HEE NE Revalidation Team Guidance to LEPs on Reporting Incidents Involving Trainees
HEE NE Revalidation Team Guidance to LEPs on Reporting Incidents Involving Trainees Principles of Revalidation Incident Reporting: The overarching principle that should be applied to all incidents involving
All Trust staff (Hospital and Community) Adverse incidents and near misses. Governance Department Approved
Trust Policy and Procedure Incident Reporting and Management Policy For use in (clinical areas): All areas of the Trust For use by (staff groups): For use for (patients / treatments): Document owner: Status:
Never Events List
Never Events List 2015-16 NHS England INFORMATION READER BOX Directorate Medical Commissioning Operations Patients and Information Nursing Trans. & Corp. Ops. Commissioning Strategy Finance Publications
(for Health Commissioned Services) Policy reference number Lead policy author/s. Teresa Candfield. Special Educational Needs and Disability
Policy title Policy reference number Lead policy author/s Serious Incident Policy (for Health Commissioned Services) CG009 Teresa Candfield Accountable director Approved by: Ratified by: Equality impact
Serious Incident: Reporting and Management Policy. September 2017
Serious Incident: Reporting and Management Policy September 2017 NHS East and North Hertfordshire Clinical Commissioning Group Page 1 of 43 DOCUMENT CONTROL SHEET Document Owner: Sheilagh Reavey, Director
Serious Incident Management Policy
Serious Incident Management Policy Standard Operating Procedure Version Version 2 Implementation Date 01 November 2017 Review Date 31 October 2019 St Helens CCG Serious Incident Management Policy Approved
SAFE STAFFING GUIDELINE
NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE Guideline title SAFE STAFFING GUIDELINE SCOPE 1. Safe staffing for nursing in accident and emergency departments Background 2. The National Institute for
Improving the reporting of medication-related safety incidents
Rationale Improving the reporting of medication-related safety incidents Research shows that organisations which regularly report more patient safety incidents usually have a stronger learning culture
Duty of Candour Policy
Duty of Candour Policy Approved by: Candy Cooley, Chairman Date of approval February 2016 Originator(s): Libby Mytton, Director of Care Introduction It is the policy of Primrose Hospice to take an honest
The Newcastle upon Tyne Hospitals NHS Foundation Trust. Serious Incidents (SIs) Reporting and Management Policy
The Newcastle upon Tyne Hospitals NHS Foundation Trust Serious Incidents (SIs) Reporting and Management Policy Version No.: 7.0 Effective From: 5 August 2015 Expiry Date: 5 August 2017 Ratified By: Corporate
Policy for the Reporting and Management of Incidents Including Serious Incidents. Version Number: 006
CONTROLLED DOCUMENT Policy for the Reporting and Management of Incidents Including Serious Incidents CATEGORY: CLASSIFICATION: PURPOSE Controlled Number: Document Policy Governance To set out the principles
Medicines Optimisation Patient Safety And Medication Safety. Dr David Cousins Associate Director Medication Safety and Medical Devices
Medicines Optimisation Patient Safety And Medication Safety Dr David Cousins Associate Director Medication Safety and Medical Devices The key elements of medicines optimisation is patient centred; makes
Burton Hospitals NHS Foundation Trusts. On: 30 May Review Date: April Corporate / Directorate. Department Responsible for Review:
POLICY DOCUMENT Burton Hospitals NHS Foundation Trusts INCIDENT AND SERIOUS INCIDENT MANAGEMENT POLICY AND PROCESS Approved by: Trust Executive Committee On: 30 May 2017 Review Date: April 2020 Corporate
Incident Reporting and Management Policy
Incident Reporting and Management Policy Document control Version: 1.0 Ratified by: None (Chief Officer approved) Date ratified: 04 May 2017 Name of originator/author: Lorraine Smedmor/Victoria Medhurst
Provisional publication of Never Events reported as occurring between 1 February and 31 March 2018
Provisional publication of Never Events reported as occurring between 1 February and 31 March 2018 Published 27 April 2018 Delivering better healthcare by inspiring and supporting everyone we work with,
SERIOUS INCIDENTS REQUIRING INVESTIGATION (SIRI) POLICY (Including Mortality review process)
SERIOUS INCIDENTS REQUIRING INVESTIGATION (SIRI) POLICY (Including Mortality review process) Solent NHS Trust policies can only be considered to be valid and up-to-date if viewed on the intranet. Please
WHAT are medication errors?
Healthcare Case Study: Errors Cause Mapping Problem Solving Incident Investigation Root Cause Analysis Errors Angela Griffith, P.E. webinars@thinkreliability.com www.thinkreliability.com Office 281-412-7766
NHS Northamptonshire Policy for the Reporting and Handling of Serious Incidents (SI)
NHS Northamptonshire Policy for the Reporting and Handling of Serious Incidents (SI) Version: 2011 Ratified by: Executive Management Team on behalf of the NHS Northamptonshire Board Date Ratified: 6 April
National Health Regulatory Authority Kingdom of Bahrain
National Health Regulatory Authority Kingdom of Bahrain THE NHRA GUIDANCE ON SERIOUS ADVERSE EVENT MANAGEMENT AND REPORTING THE PURPOSE OF THIS DOCUMENT IS TO OUTLINE SERIOUS ADVERSE EVENTS THAT SHOULD
Recommendations from National Patient Safety Agency alerts that remain relevant to the Never Events list 2018
Recommendations from National Patient Safety Agency alerts that remain relevant to the Never Events list 2018 January 2018 We support providers to give patients safe, high quality, compassionate care within
Note: Yeovil District Hospital NHS Foundation Trusts Incident Reporting Policy refers to this SIRI policy
PROCESS FOR REPORTING AND LEARNING FROM SERIOUS INCIDENTS REQUIRING INVESTIGATION Note: Yeovil District Hospital NHS Foundation Trusts Incident Reporting Policy refers to this SIRI policy Version: Ratified
Revalidation FAQs for Trainees (October 2013)
Revalidation FAQs for Trainees () Q1 What is the purpose of revalidation? The purpose of revalidation of a Doctors Licence to Practice is to give patients greater confidence in the profession and support
Review date 01/07/2014 Director of Nursing, Midwifery & Quality Expiry date 19/07/2015 Withdrawn date
Policy no: RM04 Version: 6.1 Name of policy: Incident/near-miss reporting and investigation policy (includes Serious Incidents) Effective from: 28/01/2013 Date ratified 20/07/2012 Ratified PQRS Committee
System APPROVING AND DATE. September of 34
Proceduree for performance management of serious untoward incidents reportable on the Strategic Executive Information System (StEIS) REFERENCE NUMBER APPROVING COMMITTEE(S) AND DATE REVIEW DUE DATE Version
Provisional publication of Never Events reported as occurring between 1 April and 30 June 2018
Provisional publication of Never Events reported as occurring between 1 April and 30 June 2018 Published 30 July 2018 We support providers to give patients safe, high quality, compassionate care within
Sentinel Events and S Patient Patient entinel Event Alerts Safety Act Safety Ac Revised: BW/September 2010
Sentinel Events Sentinel Events and Sentinel Event Alerts Revised: BW/September 2010 Patient Patient Safety Safety Act Act What is a Sentinel Event? 0 A sentinel event is an unexpected occurrence involving
INCIDENT REPORTING POLICY
INCIDENT REPORTING POLICY Duty of Candour Updated June 2015 Policy Title: Executive Summary: Incident Reporting Policy East Cheshire NHS trust is committed, through its Health and Safety and Risk Management
Incident Reporting and Management
Incident Reporting and Management POLICY NUMBER & CATEGORY RS 02 Risk &Safety VERSION NO & DATE 3 Feb 2014 RATIFYING COMMITTEE Clinical Governance Committee DATE RATIFIED July 2013 NEXT REVIEW DATE July
Authors Name & Title: Joan Matthews, Risk Manager & Helen Martin, Governance & Safety Lead
Incident Reporting Including Investigation and Root Cause Analysis Procedures Policy & Procedure Authors Name & Title: Joan Matthews, Risk Manager & Helen Martin, Governance & Safety Lead Scope: Trust
Serious Incident Framework. Supporting learning to prevent recurrence
Serious Incident Framework Supporting learning to prevent recurrence NHS England INFORMATION READER BOX Directorate Medical Commissioning Operations Patients and Information Nursing Trans. & Corp. Ops.
Financial Disclosure. Learning Objectives: Preventing and Responding to Sentinel Events in Surgery 10/13/2015
Preventing and Responding to Sentinel Events in Surgery Beverly Kirchner, BSN, RN, CNOR, CASC April 2014 Financial Disclosure I DO NOT have an actual, potential or perceived conflict of interest to disclose
Wrong site interventions
Publication Ref: I2017/004/1 Wrong site interventions 27 November 2017 This interim bulletin contains facts which have been determined up to the time of issue. It is published to inform the NHS and the
Serious Incident, Policy for the management of
Serious Incident, Policy for the management of The Trust strives to ensure equality of opportunity for all, both as a major employer and as a provider of health care. This procedural document has been
Auckland District Health Board Summary 1 July 2011 to 30 June 2012 Serious and Sentinel Events
DHB SSE Report 0 Auckland District Health Board Summary July 0 to 30 June 0 Serious and Sentinel Events There were 60 serious and sentinel events reported by ADHB in the July 0 to June 0 year. Events identified
Walking the Tightrope with a Safety Net Blood Transfusion Process FMEA
Walking the Tightrope with a Safety Net Blood Transfusion Process FMEA AnMed Health AnMed Health, located in Anderson, South Carolina, is one of the largest and most technologically advanced health systems
PUTTING THINGS RIGHT dealing with concerns
PUTTING THINGS RIGHT dealing with concerns Llywodraethu da calon iechyd da Good governance at the heart of good health care GUIDANCE ON THE REPORTING AND HANDLING OF SERIOUS INCIDENTS AND OTHER PATIENT
SERIOUS INCIDENT REPORTING & MANAGEMENT POLICY
SERIOUS INCIDENT REPORTING & MANAGEMENT POLICY UNIQUE REFERENCE NUMBER: QS/XX/071/V1 DOCUMENT STATUS: Approved by Quality and Safety Committee 22/03/2018 DATE ISSUED: April 2018 DATE TO BE REVIEWED: April
Clinical Governance & Risk Management Awareness. Incl. investigation of accidents, complaints and claims. Unit 2
Clinical Governance & Risk Management Awareness Incl. investigation of accidents, complaints and claims Unit 2 Unit 2 Clinical Governance & Risk Management Awareness Including investigation of accidents,
Summary guide: Safeguarding Adults: Pan Lancashire and Cumbria Multi Agency Policy and Procedures. For partner agencies staff and volunteers
Summary guide: Safeguarding Adults: Pan Lancashire and Cumbria Multi Agency Policy and Procedures For partner agencies staff and volunteers 1 1. Introduction This Summary Guide is designed to provide straightforward
Meeting of Bristol Clinical Commissioning Group Governing Body. Title: Bristol CCG Management of Serious Incidents Agenda Item: 17
Meeting of Bristol Clinical Commissioning Group Governing Body To be held on Tuesday 22 December 2015 commencing at 13:30 at the Greenway Centre, Doncaster Road, Bristol, BS10 5PY Title: Bristol CCG Management
Unit 2 Clinical Governance & Risk Management Awareness
Unit 2 Clinical Governance & Risk Management Awareness Incl. investigation of accidents, complaints and claims Unit 2 Clinical Governance & Risk Management Awareness Including investigation of accidents,
Safe medication practice what can we learn from root cause analysis and related methods?
Safe medication practice what can we learn from root cause analysis and related methods? Dr David Gerrett, Senior Pharmacist Patient Safety NHS Improvement Information Day on Medication Errors 20 October
SERIOUS PATIENT SAFETY INCIDENT REPORTING
SERIOUS PATIENT SAFETY INCIDENT REPORTING Executive Lead : Director of Nursing Author Patient Safety Manager, 029 2074 6387 Caring for People, Keeping People Well : This report underpins the Health Board
Root Cause Analysis: The NSW Health Incident Management System
Root Cause Analysis: The NSW Health Incident Management System SARAH MICHAEL, RN, GradDipQHCM PAUL DOUGLAS, MB, BS, DRACOG, MHA, FRACMA With a background in intensive care, Sarah is a Principal Analyst
HAEMOVIGILANCE POLICY
REASON FOR ISSUE: New document describing Haemovigilance System 1. INTRODUCTION NZBS has adopted the Council of Europe definition that states that haemovigilance is: The organised surveillance procedures
Serious Incident Management CCG Policy Reference: SIM 001. This policy replaces or supersedes Policy Ref SIM 001
Serious Incident Management CCG Policy Reference: SIM 001 This policy replaces or supersedes Policy Ref SIM 001 Target Audience Brief Description (max 50 words) Action Required Governing Body members,
Learning from Incidents
Learning from Incidents Reporting, Managing and Investigating Policy and Guidance Version: 7 Executive Lead: Lead Author: Executive Director for Quality and Safety Patient Safety Manager Approved Date:
This policy applies to all employees of Meditech, service users, their families, guardians and advocates.
INCIDENT REPORTING PURPOSE The purpose of this policy is to ensure that all incidents are identified and reported in a timely and accurate manner. This will assist Meditech to enhance the quality of programs
Medication Safety in the Operating Room: Using the Operating Room Medication Safety Checklist
Medication Safety in the Operating Room: Using the Operating Room Medication Safety Checklist CPSI Safe Surgery Saves Lives Workshop Montréal, QC 29Mar2011 Julie Greenall, RPh, BScPhm, MHSc, FISMPC Institute
Serious Incident Report Public Board Meeting 28 July 2016
Serious Incident Report Public Board Meeting 28 July 2016 Presented for: Presented by: Author Previous Committees Governance Dr Yvette Oade, Chief Medical Officer Louise Povey, Serious Incidents Investigations
Kate Beaumont. Strategy Advisor, NPSA Head of Clinical Interventions, National Patient Safety Campaign.
Why Safety Matters Kate Beaumont Strategy Advisor, NPSA Head of Clinical Interventions, National Patient Safety Campaign Catherine.beaumont@npsa.nhs.uk www.npsa.nhs.uk About the NPSA What we are: Arm s
Degree of harm FAQ Contents
Degree of harm FAQ Contents Introduction... 2 Definitions... 2 Frequently Asked Questions... 4 1. What is the difference between an incident resulting in no harm (impact not prevented) and no harm (impact
Reducing Risk: Mental health team discussion framework May Contents
Reducing Risk: Mental health team discussion framework May 2015 Contents Introduction... 3 How to use the framework... 4 Improvement area 1: Unscheduled absence and managing time off the ward... 5 Improvement
Patient Safety (PS) 1) A collaborative process is used to develop policies and/or procedures that address the accuracy of patient identification.
Patient Safety (PS) Standard PS.1 [Patient identification] The organization has established procedures for accurately identifying patients. Intent of PS.1 Wrong-patient errors occur in virtually all aspects
Ensuring our safeguarding arrangements act to help and protect adults PRACTICE GUIDANCE FOR REPORTING MEDICATION INCIDENTS INTO SAFEGUARDING
Ensuring our safeguarding arrangements act to help and protect adults PRACTICE GUIDANCE FOR REPORTING MEDICATION INCIDENTS INTO SAFEGUARDING Contents Page 1.0 Purpose 2 2.0 Definition of medication error
Patient Safety Initiatives of the VA National Center for Patient Safety
Patient Safety Initiatives of the VA National Center for Patient Safety At the Quality Colloquium at Harvard University John Gosbee, MD, MS August 27, 2003 National Center for Patient Safety Department
Department of Defense INSTRUCTION. SUBJECT: Military Health System (MHS) Patient Safety Program (PSP) (MHSPSP)
Department of Defense INSTRUCTION NUMBER 6025.17 August 16, 2001 SUBJECT: Military Health System (MHS) Patient Safety Program (PSP) (MHSPSP) ASD(HA) References: (a) Sections 742 and 754 of the Floyd D.
Why do we make mistakes? Human factors in transfusion practice
Why do we make mistakes? Human factors in transfusion practice East of England Regional Transfusion Committee Blood transfusion: What now? What if? What next? Alison Watt SHOT Operations Manager Paula
How to Report Medication Safety Incidents from a GP Practice on the National Reporting and Learning System (NRLS)
pecialist Pharmacy ervice Medicines Use and afety How to Report Medication afety Incidents from a GP Practice on the National Reporting and Learning ystem (NRL) This document provides a quick explanation
NHS Standard Contract for 2015/16
NHS Standard Contract for 2015/16 Discussion paper for stakeholders response document NHS Standard Contract 2015/16 Discussion paper for stakeholders response document Version number: 1 First published:
NERC Improving Human Performance
NERC Improving Human Performance Sentinel Event Reporting, Analysis and Prevention in Healthcare March 28, 2012 Charles A. Mowll, FACHE, CSSBB Executive Vice President The Joint Commission Healthcare Worker
Allegations against Staff in relation to Safeguarding Children/Young People and Vulnerable Adults Procedure.
Allegations against Staff in relation to Safeguarding Children/Young People and Vulnerable Adults Procedure. April 2015 Document Profile Type i.e. Strategy, Policy, Procedure, Guideline, Protocol Title
The Care Act, 2014 and its implications for practice
The Care Act, 2014 and its implications for practice Karl Mason March 2016 Community Care Law 1948-2014 Poor Laws 1948 1968 1970 1983 1984 1990 1995 1996 2000 2001 Care Act 2014 1948 National Assistance
National Reporting and Learning Service (NRLS) Data Quality Standards. Guidance for organisations reporting to the Reporting and Learning System (RLS)
National Reporting and Learning Service (NRLS) Data Quality Standards Guidance for organisations reporting to the Reporting and Learning System (RLS) September 2009 Introduction to the NRLS The are designed
SCDHSC0335 Contribute to the support of individuals who have experienced harm or abuse
Contribute to the support of individuals who have experienced harm or Overview This standard identifies the requirements when you contribute to the support of individuals who have experienced harm or.
BAY-ARENAC BEHAVIORAL HEALTH AUTHORITY POLICIES AND PROCEDURES MANUAL
Page: 1 of 14 Policy It is the policy of Bay-Arenac Behavioral Health Authority (BABHA) that all adverse events, such as unusual events (including risk), critical incidents (including all deaths) and sentinel
Prevention of Family Violence Project Lead. TBC, pending professional background
Prevention of Family Violence Project Lead Position Title: Prevention of Family Violence Project Lead Classification: Grade 2-3 Employment status Part-time, Fixed Term contract. Enterprise Agreement: Reports
Subject: Hospital-Acquired Conditions (Page 1 of 5)
Subject: Hospital-Acquired Conditions (Page 1 of 5) Objective: I. To facilitate safe patient care for all Health Share/Tuality Health Alliance (THA) members. II. To encourage and support provider efforts
HALF YEAR REPORT ON SENTINEL EVENTS
HALF YEAR REPORT ON SENTINEL EVENTS 1 October 2008-31 March 2009 Jul 2009-0 - TABLE OF CONTENTS Chapter Page 1. Executive Summary...... 2 2. Introduction 5 3. Sentinel Events Reported... 6 From 1 October
How effective and sustainable are Root. HFESA Conference
How effective and sustainable are Root Cause Analysis (RCA) investigations 27 th November 2017 HFESA Conference Peter Hibbert, Matthew Thomas, Anita Deakin, Bill Runciman, Jeffrey Braithwaite Acknowledgements:
Insert heading depending on line line length; please delete 2013/14. cover options once. other cover options once you have chosen one.
FOR ACUTE, AMBULANCE, COMMUNITY AND MENTAL HEALTH AND LEARNING DISABILITY SERVICES Insert heading depending Insert on NHS line Standard Insert heading on line length; length; Contract depending on please
Smart Pumps and Drug Libraries The Way Forward
Smart Pumps and Drug Libraries The Way Forward Kathryn Phillips North West Regional MI Centre The first stop for professional medicines advice Outline The drivers behind the development/use of Smart Pumps
Contact Hours (CME version ONLY) Suggested Target Audience. all clinical and allied patient care staff. all clinical and allied patient care staff
1 Addressing Behaviors That Undermine a Culture of Safety PA CE CME FL 8/31/2016 2 2 7 3 43 1.0 1.0 1.0 all staff Sentinel Event Alert, Issue 40: Behaviors that undermine a culture of safety 2 Adverse
HILLSROAD SIXTH FORM COLLEGE. Safeguarding Policy. Date approved by Corporation: July 2017
HILLSROAD SIXTH FORM COLLEGE Safeguarding Policy Date approved by Corporation: July 2017 Interim update with non-substantive changes approved by the Principal March 2016 Post of member of staff responsible:
Safety Reporting in Clinical Research Policy Final Version 4.0
Safety Reporting in Clinical Research Policy Final Version 4.0 Category: Summary: Equality Assessment undertaken: Impact Policy The Medicines for Human Use (Clinical Trials) Regulations 2004 and subsequent
Incident Report Form (Version 14)
Incident Report Form (Version 14) Instructions: If you become aware of an incident you should let your line manager know as soon as possible then report the incident by providing an answer for every question
A summary of the Care Quality Commission s Report into Marie Stopes International
A summary of the Care Quality Commission s Report into Marie Stopes International Life 1 Mill Street Leamington Spa CV31 1ES 01926 312 272 www.lifecharity.org.uk SPUC Unit B, 3 Whitacre Mews Stannary Street
Nasogastric Intubation and Check Image Interpretation. Robert Law DCR, MRCR (Hon). Consultant GI Radiographer - Frenchay Hospital, Bristol
Nasogastric Intubation and Check Image Interpretation. Robert Law DCR, MRCR (Hon). Consultant GI Radiographer - Frenchay Hospital, Bristol National Patient Safety Agency (NPSA) NPSA suggests 171,000 fine
INCIDENT POLICY Page 1 of 15 July 2017
Page 1 of 15 Policy Applies To All Mercy Hospital Staff Credentialed Medical Specialists and Allied Health Personnel are required to indicate understanding of the incident policy via the credentialing
The CARE CERTIFICATE. Duty of Care. What you need to know. Standard THE CARE CERTIFICATE WORKBOOK
The CARE CERTIFICATE Duty of Care What you need to know Standard THE CARE CERTIFICATE WORKBOOK Duty of care You have a duty of care to all those receiving care and support in your workplace. This means
Policy 1.1 Protection of Human Rights and Freedom from Abuse and Neglect
Disability Service Standard 1 Kids Are Kids! Therapy & Education Centre Inc. Policy 1.1 Protection of Human Rights and Freedom Last Amended: 15/04/2015 Date Ratified: 10/01/2016 Next Review: 10/01/2017
Health Care Support Worker. Job description
Health Care Support Worker Job description Date: December 2015 Context Barts Health NHS Trust is one of Britain s leading healthcare providers and the largest trust in the NHS. It was created on 1 April
Quality Report. Marie Stopes International; 1 Conway Street Fitzroy Square London W1T 6LP Tel: Website:
Marie Stopes International Quality Report Marie Stopes International; 1 Conway Street Fitzroy Square London W1T 6LP Tel: 02076366200 Website: www.mariestopes.org.uk Date of inspection visit: 28 July 2016
ALLOCATION OF RESOURCES POLICY FOR CONTINUING HEALTHCARE FUNDED INDIVIDUALS
ALLOCATION OF RESOURCES POLICY FOR CONTINUING HEALTHCARE FUNDED INDIVIDUALS APPROVED BY: South Gloucestershire Clinical Commissioning Group Quality and Governance Committee DATE Date of Issue:- Version
Adverse Incident Reporting Form Provider Instructions and Definitions
Adverse Incident Reporting Form Provider Instructions and Definitions Please use the following instructions when reporting Adverse Incidents to the health plans. Providers are required to notify the health
CHAPTER 12 -QUALITY MANAGEMENT AND PERFORMANCE IMPROVEMENT
CHAPTER 12 -QUALITY MANAGEMENT AND PERFORMANCE IMPROVEMENT 12.0 QUALITY MANAGEMENT REQUIREMENTS Health Choice Integrated Care works in partnership with providers to continuously monitor and improve the
Overview of Root Cause Analysis
Overview of Root Cause Analysis Brian Harmon Quality Consultant Performance Improvement University of Minnesota Medical Center February 25, 2006 What is a Sentinel Event? A sentinel event is an unexpected
Our five year plan to improve health and wellbeing in Portsmouth
Our five year plan to improve health and wellbeing in Portsmouth Contents Page 3 Page 4 Page 5 A Message from Dr Jim Hogan Who we are What we do Page 6 Page 7 Page 10 Who we work with Why do we need a
Setting the Standards- Safeguarding our Patients
Inaugural IMSN Conference 1 st Oct 2010 - Networking for safety Setting the Standards- Safeguarding our Patients June O Shea and Paul Tighe A hospital is no place to be sick Samuel Goldwyn Outline Introduction
We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.
Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Spire Wellesley Hospital Eastern Avenue, Southend-on-Sea, SS2
Reporting and Investigation Guidelines for Serious Incidents Cambridgeshire and Peterborough Clinical Commissioning Group
Reporting and Investigation Guidelines for Serious Incidents Cambridgeshire and Peterborough Clinical Commissioning Group Ratification Process Lead Authors: Developed by: Approved by: Ratified by: Paul
Social care guideline Published: 14 March 2014 nice.org.uk/guidance/sc1
Managing medicines in care homes Social care guideline Published: 14 March 2014 nice.org.uk/guidance/sc1 NICE 2018. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-conditions#notice-ofrights).
Care Skillsbase Skills Check topic list (note: excludes Personal Assistant Skills Checks)
Care Skillsbase Skills Check topic list (note: excludes Personal Assistant Skills Checks) A Abuse and neglect (types of) SC6 SC36 Abuse and neglect (what to do about) SC6 SC36 Accepting gifts and money
Serious Reportable Events in Healthcare 2011 Update
Serious Reportable Events in Healthcare 2011 Update July 19, 2011 1 Overview Purpose 2002, 2006, 2011 Facilitate uniform, comparable public reporting Enable systematic learning Ensure currency & appropriateness
SAFEGUARDING OF VULNERABLE ADULTS POLICY
SAFEGUARDING OF VULNERABLE ADULTS POLICY Practice lead: Dr Tim Sephton INTRODUCTION The purpose of this document is to set out the policy of the Practice in relation to the protection of vulnerable adults.
Level 4 Diploma in Adult Care
Level 4 Diploma in Adult Care Criteria for qualification For awarding organisations developing the new regulated qualifications framework (RQF) qualifications September 2016 1 Context In 2015, following
Worcestershire Primary Care Trust. Safeguarding Adults Policy. Quality and Safety Committee Date ratified: March 2009
Worcestershire Primary Care Trust Safeguarding Adults Policy Version: Final Ratified by: Quality and Safety Committee Date ratified: March 2009 Name of originator/author: Vicky Preece Name of responsible
POLICY & PROCEDURE FOR INCIDENT REPORTING
POLICY & PROCEDURE FOR INCIDENT REPORTING APPROVED BY: South Gloucestershire Clinical Commissioning Group Quality and Governance Committee DATE February 2015 Date of Issue: 25 February 2015 Version No:
Meeting the NEW RCN Standards for Infusion Therapy in practice
Meeting the NEW RCN Standards for Infusion Therapy in practice sumanshrestha@nhs.net Suman Shrestha MSc BSc RN Advanced Nurse Practitioner Intensive Care Frimley Park Hospital suman_sr FRIMLEY PARK HOSPITAL
Safeguarding Vulnerable Persons at Risk of Abuse
SAFEGUARDING Safeguarding Vulnerable Persons at Risk of Abuse CareChoice Staff All staff employed by CareChoice are aware that safeguarding residents is an essential part of their duty and that there is