...Recommended as adjuncts to Patient Safety Incident Investigation training
PATIENT SAFETY INCIDENT RESPONSE FRAMEWORK (PSIRF)
and its Supporting Guidance
from NHS England and NHS Improvement
An approach to incident management which facilitates inquisitive examination of patient safety incidents from a 'systems perspective' rather than as part of a 'framework of accountability'.
This approach supports a compassionate; proportionate; systemic and proficient response to patient safety incidents, anchored in the principles of openness; fair accountability; learning; and continuous improvement.
The Essentials of Patient Safety
by Charles Vincent
This free resource makes the essentials of patient safety available to everyone. It is taken from the book Patient Safety (2nd edition, 2010).
The topics addressed include the evolution of patient safety; the research that underpins the area, understanding how things go wrong, and the practical action needed to reduce error and harm and, when harm does occur, to help those involved.
LEARNING FROM ADVERSE EVENTS
Chartered Institute of Ergonomics & Human Factors
This white paper describes nine key principles designed to help organisations take a human factors perspective to investigating and learning from incidents or adverse events. It is designed for anyone in any industry or service who is:
responsible for managing significant risk
involved in investigating incidents
interested in organisational learning