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Learning from Serious Incidents: Implementing the CQC Recommendations – Speaker News and Updates

In July 2016, the Care Quality Commission has called for a step change in the way that serious incidents are investigated and managed in the NHS. This conference focuses on learning from serious incidents: improving the quality of investigations and ensuring lessons are learned and embedded into practice and will provide a practical guide to implementing the five opportunities for improvement as identified through the Care Quality Commission review.

Speaker Presentations & Updates

EXTENDED SESSION: Improving the way organisations investigate, communicate and learn when things go wrong including prioritisation of incidents that require full investigation and developing methods for managing and learning from other types of incident

Dr Umesh Prabhu Medical Director Wrightington, Wigan and Leigh NHS Foundation Trust

  • learning from the CQC review into the quality of investigation reports
  • help and encouraging improvement
  • implementing the CQC recommendations on serious incident investigation
  • what should be reported to CQC
  • developing criteria for full investigation under the serious incident framework
  • good practice in the investigation of near misses
  • ensuring a proportionate response: methods for managing and learning from other types of incidents
  • ensuring conclusions in investigations will lead to inform learning and change practice
  • key steps within the Serious Incident Framework

Dr Umesh Prabhu Biography:  

Following my own mistake in 1992, I developed a keen interest in patient safety, medical errors, clinical governance, why doctors make mistakes, organisational governance, culture, leadership and institutional racism.

I have given nearly 100 lectures and conducted 70 workshops on various aspects of patient safety, professional regulation and governance.

I joined Wrightington, Wigan and Leigh NHS Foundation Trust, and by working with the Trust Board and Chief Executive have completely transformed Trust values, value based leadership, culture and governance. 

Today 450 less patients die in our Trust compared with 2008.  All 22 quality measurements have improved, we made a £4m surplus in 2003/14, we have 170 patient safety champions and robust governance.

Using human factors principles to develop solutions that reduce the risk of the same incident happening again

Nicola Davey Trustee Clinical Human Factors Group

  • human factors principles to reduce reoccurrence
  • designing processes to minimize human error
  • using staff and patient stories to inspire the team to improve
  • engaging patients
  • examples in practice

Nicola Davey Full presentation Click Here

Nicola Davey Pre-Event Abstract:

In this session Nicola will consider the ‘error spectrum’ from common place to rare and use examples of every day practice to:

Explore error from different perspectives, including that of patients

  • Introduce a model that helps us appreciate the interaction between people and systems
  • Explore how our perception of risk and our default system response can fail our patients, our staff and our organisations
  • Signpost to places where you can find out more

Nicola Davey Biography:

Nicola is an experienced pharmacist and quality improvement practitioner who specialises in service improvement. She has worked in the acute and primary care sectors, at local, regional and national level. She was Senior Associate at the NHS Institute for Innovation and Improvement for 5 years and is now Director of the Quality Improvement Clinic. Nicola is a Trustee for the Clinical Human Factors Group (CHFG), a charity which works with clinical professionals and managers to make healthcare safer. She is also Faculty Lead for England for the IHI’s Open School supporting clinical trainees.

Future events of interest:

Root Cause Analysis: 2 Day Intensive Training Course

We are running this event in London on Wednesday 24 – Thursday 25 May 2017Tuesday 25 — Wednesday 26 July 2017Tuesday 19 — Wednesday 20 September 2017 and Tuesday 28 — Wednesday 29 November 2017

In Manchester on Wednesday 12 — Thursday 13 July 2017

Measuring & Monitoring Patient Safety: Patient Safety Surveillance in Real Time
Friday 10 March 2017 
De Vere West One Conference Centre, London

Measuring, Understanding and Acting on Patient Experience Insight
Friday 24 March 2017 
De Vere West One Conference Centre, London

Root Cause Analysis Review & Quality Assurance Masterclass
Friday 28 April 2017 
De Vere West One Conference Centre, London

Investigation of Deaths in NHS Trusts: Implementing the CQC Recommendations
Monday 8 May 2017 
De Vere West One Conference Centre, London


23 February 2017

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