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HSIB Investigation report – transition from child mental health services to adult

This investigation followed the Healthcare Safety Investigation Branch being notified of an 18-year-old who died by suicide shortly after transitioning from child and adolescent to adult mental health services. The investigation identified possible issues regarding […]

By | 2018-07-10T09:57:52+00:00 10th July, 2018|Learning Resources, Featured|0 Comments

HSIB first national investigation report – wrong prosthesis

The Healthcare Safety Investigation Branch (HSIB) has published its first investigation report relating to a surgical never event.

The patient is a 63-year-old man who underwent hip replacement surgery. During this surgery, incompatible components were used. […]

By | 2018-06-28T13:42:24+00:00 28th June, 2018|Learning Resources, Featured|0 Comments

Measuring Safety Culture

This Health Foundation evidence scan provides a brief overview of some of the tools available to measure safety culture and climate in health care.

Safety culture refers to the way patient safety is thought about and […]

By | 2018-05-21T14:39:37+00:00 21st May, 2018|Learning Resources, Featured|0 Comments

Contributory factors in surgical incidents as delineated by a confidential reporting system

Confidential reporting systems play a key role in capturing information about adverse surgical events. However, the
value of these systems is limited if the reports that are generated are not subjected to systematic analysis. The aim […]

By | 2018-03-19T09:23:02+00:00 19th March, 2018|Learning Resources|0 Comments

Systems thinking – a new direction in healthcare incident investigation

The Health Foundation’s Evidence into Practice Programme sponsored the production of a 3 minute animation led by Thomas Jun and Patrick Waterson at Human Factors and Complex Systems Research Group, Loughborough University. This highly engaging […]

By | 2017-12-08T11:01:18+00:00 4th October, 2017|Learning Resources|0 Comments

Anaesthesia Safety Network

The Anaesthesia Safety Network is an online reporting tool designed to improve patient safety.  Their Newsletter provides excellent examples of case studies.  If you would like to view the Newsletters please go to http://www.anesthesiasafetynetwork.com/index.php/en/

By | 2017-09-26T13:15:27+00:00 26th September, 2017|Learning Resources, Uncategorised|0 Comments

NMC Consultation on standards of proficiency for registered nurses

The NMC have currently gone out to consultation on the draft standards in proficiency for registered nurses, the deadline for the consultation is the 12th September 2017.

We believe that nurses’s of the future require not […]

By | 2017-12-08T11:01:19+00:00 4th September, 2017|Resources, Learning Resources|0 Comments

TED Time Escalation Decision Learning package

“The Little Voice Inside”


Hypoxic Ischaemic Encephalopathy (HIE) occurs when the foetal brain does not receive enough oxygen. This can lead to severe impairment or death of the […]

By | 2017-12-08T11:01:19+00:00 6th July, 2017|Learning Resources|0 Comments

Works system design for patient safety: The SEIPS Model

Most errors and inefficiencies in patient care arise not from the solitary actions of individuals but from conflicting, incomplete, or sub-optimal systems of which they are a part and with which they interact. To improve […]

By | 2017-12-08T11:01:19+00:00 20th June, 2017|Resources, Learning Resources|0 Comments