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The second edition of this well-received book, the first to provide detailed guidance on how to conduct incident investigations in primary care, has been thoroughly revised and updated throughout to reflect the current nomenclature for different aspects of the investigatory process in the UK and the latest format for incident reporting. Key features: Explains how to recognise a serious clinical incident, how to conduct a root cause analysis (RCA) investigation, and how and when duty of candour applies Covers the technical aspects of serious incident recognition and report writing Includes a wealth of practical advice and 'top tips', including how to manage the common pitfalls in writing reports Offers practical advice as well as some new and innovative tools to help make the RCA process easier to follow Explores the all-important human factors in clinical incidents in detail, with multiple examples and worked-through cases studies as well as in-depth sample reports and analysis. At a time of increasing regulatory scrutiny and medico-legal risk, in which failure to manage appropriately can have serious consequences both for service organisations and for individuals involved, this concise and convenient book continues to provide a master class for anyone performing RCA and aiming to demonstrate learning and service improvement in response to serious clinical incidents. It is essential reading for any clinical or governance leads in primary care, including GP practices, 'out-of-hours', urgent care centres, prison health and NHS 111. It also offers valuable insights to any clinician who is in training or working at the coal face who wishes to understand how serious clinical incidents are investigated and managed.
v. 1. Research findings -- v. 2. Concepts and methodology -- v. 3. Implementation issues -- v. 4. Programs, tools and products.
"Nurses play a vital role in improving the safety and quality of patient car -- not only in the hospital or ambulatory treatment facility, but also of community-based care and the care performed by family members. Nurses need know what proven techniques and interventions they can use to enhance patient outcomes. To address this need, the Agency for Healthcare Research and Quality (AHRQ), with additional funding from the Robert Wood Johnson Foundation, has prepared this comprehensive, 1,400-page, handbook for nurses on patient safety and quality -- Patient Safety and Quality: An Evidence-Based Handbook for Nurses. (AHRQ Publication No. 08-0043)." - online AHRQ blurb, http://www.ahrq.gov/qual/nurseshdbk/
This User’s Guide is intended to support the design, implementation, analysis, interpretation, and quality evaluation of registries created to increase understanding of patient outcomes. For the purposes of this guide, a patient registry is an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves one or more predetermined scientific, clinical, or policy purposes. A registry database is a file (or files) derived from the registry. Although registries can serve many purposes, this guide focuses on registries created for one or more of the following purposes: to describe the natural history of disease, to determine clinical effectiveness or cost-effectiveness of health care products and services, to measure or monitor safety and harm, and/or to measure quality of care. Registries are classified according to how their populations are defined. For example, product registries include patients who have been exposed to biopharmaceutical products or medical devices. Health services registries consist of patients who have had a common procedure, clinical encounter, or hospitalization. Disease or condition registries are defined by patients having the same diagnosis, such as cystic fibrosis or heart failure. The User’s Guide was created by researchers affiliated with AHRQ’s Effective Health Care Program, particularly those who participated in AHRQ’s DEcIDE (Developing Evidence to Inform Decisions About Effectiveness) program. Chapters were subject to multiple internal and external independent reviews.
Americans should be able to count on receiving health care that is safe. To achieve this, a new health care delivery system is needed â€" a system that both prevents errors from occurring, and learns from them when they do occur. The development of such a system requires a commitment by all stakeholders to a culture of safety and to the development of improved information systems for the delivery of health care. This national health information infrastructure is needed to provide immediate access to complete patient information and decision-support tools for clinicians and their patients. In addition, this infrastructure must capture patient safety information as a by-product of care and use this information to design even safer delivery systems. Health data standards are both a critical and time-sensitive building block of the national health information infrastructure. Building on the Institute of Medicine reports To Err Is Human and Crossing the Quality Chasm, Patient Safety puts forward a road map for the development and adoption of key health care data standards to support both information exchange and the reporting and analysis of patient safety data.
From 1 October 2013, RIDDOR 2013 comes into force, which introduces significant changes to the existing reporting requirements. The main changes are to simplify the reporting requirements in the following areas: the classification of major injuries to workers is being replaced with a shorter list of 'specified injuries'; the previous list of 47 types of industrial disease is being replaced with eight categories of reportable work-related illness; fewer types of dangerous occurrence require reporting. This leaflet aims to help employers and others with reporting duties under RIDDOR, to comply with RIDDOR and to understand reporting requirements.
This step-by-step guide takes the reader through the complex process of investigating serious incidents in health, social care, and criminal justice environments, acknowledging differences of culture and context that shape an investigation. Taking a multi-disciplinary approach, Part 1 begins by exploring the key principles of investigation, including ethical and legal perspectives, the involvement of families and carers, and being aware of unconscious bias, among other issues. Part 2 outlines in detail the conduct of investigations, from planning to processing the findings, before moving on to Part 3, carrying them out in diverse settings. Further chapters then look at investigating within diverse environments before moving on to to Part 4 which deals with reviewing and analysing the evidence collected and writing up the investigation. This final part also examines the pivotal issue of learning from the investigation and disseminating the report. The inclusion of case studies, models of good practice, and vignettes enables the reader to view each stage of the process in context and drive the transformation of practice. This practical resource is designed to support health and social care professionals who undertake investigations as part of their role, including nurses, allied health practitioners, social workers, doctors, and psychologists, as well as military personnel and law enforcers. It is an essential companion.