patient safety

Risk Management

Identify Risks

Assess Risks

Risk Mitigation

Risk Monitoring

(In background a culture of psychological safety to speak up/report concerns and to share learning)

My Experience

Clinical

-pre op Assessment (look in advance so can act in time)

-risk scoring and SDM discussions with patients

-minimise risk on day (monitoring, post op location)

-report issues (recently did a form for missed group and save)

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Orgsnisations

New bill:it will transfer to be under CQC!!!

HSSIB is the independent national organisation that investigates patient-safety concerns across healthcare in England, using a systems/human-factors approach rather than attributing blame. It evolved from the Healthcare Safety Investigation Branch (HSIB).

HSSIB currently provides independent, systems-based national patient-safety investigation. However, under the 2026 Health Bill the Government proposes to abolish HSSIB as a standalone organisation and transfer its functions to the CQC. The intention is to simplify the patient-safety landscape while retaining the investigation function, although there is debate about how its independence and learning-focused ‘safe space’ approach will be preserved within a regulator.”

SALG

Health Services Safety Investigations Body (HSSIB).

FOUNDED 2023. FULLY independent arm’s length body of the Department of Health and Social Care.

We investigate patient safety concerns across the NHS in England and in independent healthcare settings where safety learning could also help to improve NHS care.

investigations aim to reduce patient harm by:

• Supporting involvement of patients, families and carers.

• Supporting staff to carry out their roles and care for patients safely.

• Creating safer healthcare environments and processes.

• Making healthcare services more efficient.

• Sharing best practice and innovations in patient care.

Dash review

Her central finding was that the patient-safety landscape had become fragmented, with considerable duplication and overlap, and needed to be streamlined, simplified and consolidated.

HSSIB currently provides independent, systems-based national patient-safety investigation. However, under the 2026 Health Bill the Government proposes to abolish HSSIB as a standalone organisation and transfer its functions to the CQC. The intention is to simplify the patient-safety landscape while retaining the investigation function, although there is debate about how its independence and learning-focused ‘safe space’ approach will be preserved within a regulator.”

Governance involvement

Education

-wrote modules on cpoc and risk scoring

QI

-hat project and airway project

Prizes

-pt safety prize…

Thinking still..