#WeNurses - Thursday 24th May 2018 8pm (GMT Standard Time) Learning from serious incidents

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The NHS is one of the busiest organisations in the world, treating over 1 million patients every 36 hours.  We aim to provide the best possible care but unfortunately on rare occasions things can go wrong.  These errors are rarely the fault of individuals but are the actually caused by the systems they work in.

Serious Incidents should accordingly be reported and investigated in the NHS so that action can be taken to prevent the same incident from happening again.

Existing national guidelines describe how the NHS should do a number of things when identifying a Serious Incident, including setting up an investigation team; involving patients, carers and staff; scoping and defining an investigation; developing an action plan and submitting a report to commissioners.

However, evidence from patients, families, carers and staff have revealed weaknesses in the way NHS organisations investigate, communicate and learn when things go wrong.

  • investigations do not always properly involve and support patients, families, carers and staff
  • many are undertaken by staff who do not have the necessary training, or time given their other responsibilities;
  • some focus too narrowly on care in specific settings and do not consider the care a patient received from several different organisations;
  • too often the investigation does not follow a systems-based methodology; and
  • too many make weak recommendations

To support the NHS to address these weaknesses, NHS Improvement wants to talk to frontline staff so they can understand the factors that undermine investigations, and limit their potential as a tool for learning and improvement.  

On the evening of May 24th NHS Improvement will host a #WeNurses Tweetchat to seek your views about how and when the healthcare system should investigate serious incidents. Your involvement is important - feedback will be used to inform the revision of the Serious Incident framework by the end of 2018 which will result in better processes to support staff when things go wrong.

Further details on our engagement can be found on the NHS Improvement website HERE





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 Chat Summary

 

Question 1 asked what makes a good patient safety investigation: 






Question 2 asked what gets in the way ...






Question 3 addressed support:






Question 4 was all about resources: 






The final question looked at changes: 






Two poll tweets were shared during the discussion, the results are below:




Please take some time to participate in the wider consultation regarding the Serious Incidents Framework - the link is below:








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 #WeNurses transcript

 
@sindykingnnu
24 May 2018 20:00
RT @WeCYPnurses: #wenurses on serious incidents ... starting at 8pm https://twitter.com/WeNurses/status/999724228009218049
@_Luqman_Ahmad_
24 May 2018 20:00
RT @WeNurses: In 1/2 an hour #WeNurses with @ptsafetyNHS @Lauren_e_Mosley & @SafetyDonna Discussing Serious Incidents and the Serious In…
@Jo3_NHS
24 May 2018 20:01
RT @WeNurses: 10 mins until #WeNurses Tonight we are exploring serious incidents Have a watch of this background video, to find out mor…
@WeNurses
24 May 2018 20:01
Hello and welcome to #WeNurses Please tweet us a hello if you are joining us this evening to discuss "Serious Inc… https://twitter.com/i/web/status/999727092131647489
@WeNurses
24 May 2018 20:01
It's great to have the @ptsafetyNHS team with us this evening - welcome @Lauren_e_Mosley & @SafetyDonna #WeNurses https://t.co/YclzHJxzHI
@WeStudentNurse
24 May 2018 20:01
RT @WeNurses: Hello and welcome to #WeNurses Please tweet us a hello if you are joining us this evening to discuss "Serious Incidents" ht…
@WeNurses
24 May 2018 20:02
So lets get started with QUESTION 1 #WeNurses https://t.co/Pn1WbNdD42
@LeanneHPatrick
24 May 2018 20:02
RT @WeNurses: Hello and welcome to #WeNurses Please tweet us a hello if you are joining us this evening to discuss "Serious Incidents" ht…
@AgencyNurse
24 May 2018 20:02
Hello Teresa here #WeNurses
@WeDistrictNurse
24 May 2018 20:02
RT @WeNurses: So lets get started with QUESTION 1 #WeNurses https://t.co/Pn1WbNdD42
@LeanneHPatrick
24 May 2018 20:02
@WeNurses Hello! Student nurse, here with my learning hat firmly on #WeNurses
@WeCYPnurses
24 May 2018 20:02
Question 1 #WeNurses https://twitter.com/WeNurses/status/999727248075821057
@WeNurses
24 May 2018 20:03
Hello and welcome #WeNurses https://twitter.com/JonathanCliffe8/status/999727392326381568
@WeNurses
24 May 2018 20:03
Hello there #WeNurses https://twitter.com/PaedCritCareODN/status/999727470340341762
@AgencyNurse
24 May 2018 20:03
Hello guys :D #WeNurses https://twitter.com/WeNurses/status/999727155507548161
@WeStudentNurse
24 May 2018 20:03
RT @WeNurses: So lets get started with QUESTION 1 #WeNurses https://t.co/Pn1WbNdD42
@WeNurses
24 May 2018 20:04
Right now.... We are chatting via #wenurses about "Learning from serious incidents" All welcome.... Just ad… https://twitter.com/i/web/status/999727819390423040
@LeanneHPatrick
24 May 2018 20:04
RT @WeNurses: So lets get started with QUESTION 1 #WeNurses https://t.co/Pn1WbNdD42
@lilian_wittman
24 May 2018 20:04
#WeNurses hi guys Lilian saying hello ??. The people conducting the investigation must be impartial and non judgeme… https://twitter.com/i/web/status/999727982250950656
@WeNurses
24 May 2018 20:05
@AgencyNurse @LeanneHPatrick @Lauren_e_Mosley welcome along.. thanks for joining #WeNurses
@XMcVey
24 May 2018 20:05
@WeNurses Hello ??????? following the chat on my bus home! #wenurses
@AgencyNurse
24 May 2018 20:05
One that ultimately reduces the risk that the same - or similar - doesn't happen again ! #WeNurses https://twitter.com/WeNurses/status/999727248075821057
@SafetyDonna
24 May 2018 20:05
#wenurses How can we make this happen https://t.co/IMpnHJu2N1
@WeNurses
24 May 2018 20:05
All good points Lilian #WeNurses https://twitter.com/lilian_wittman/status/999727982250950656
@WeNurses
24 May 2018 20:06
Hello there #WeNurses https://twitter.com/xxDigitalLovexx/status/999728201357291520
@NRCUK
24 May 2018 20:06
Listening in to #wenurses this eve on "Learning from serious incidents" with my safeguarding and quality IT hat on.....
@WeNurses
24 May 2018 20:06
RT @SafetyDonna: #wenurses How can we make this happen https://twitter.com/Lauren_e_Mosley/status/999727700116934656
@XMcVey
24 May 2018 20:06
RT @AgencyNurse: One that ultimately reduces the risk that the same - or similar - doesn't happen again ! #WeNurses https://twitter.com/WeNurses/status/999727248075821057
@jmcefalas
24 May 2018 20:06
RT @AgencyNurse: One that ultimately reduces the risk that the same - or similar - doesn't happen again ! #WeNurses https://twitter.com/WeNurses/status/999727248075821057
@WeLDnurses
24 May 2018 20:06
Question 1 - incase you missed it #WeNurses https://twitter.com/WeNurses/status/999727248075821057
@WeNurses
24 May 2018 20:07
@XMcVey safe journey :) thanks for saying hi from your bus :) #wenurses
@AlanJCard
24 May 2018 20:07
Hi everyone, Alan here. Excite to join you in geeking out about #ptsafety incident investigation! #wenurses
@WeNurses
24 May 2018 20:07
@NRCUK welcome Nick :) #wenurses
@lilian_wittman
24 May 2018 20:07
#WeNurses I also think that human factors should be taken into account as there is usually a chain of events leading up to an incident.
@schoolnurse17
24 May 2018 20:07
@SafetyDonna by finding out what actually happened and why .... and the applying that learning ? #WeNurses
@SafetyDonna
24 May 2018 20:08
@NRCUK #wenurses Hi Nick, it will be good to hear your thougths
@WeNurses
24 May 2018 20:08
What do others think ? #WeNurses https://twitter.com/lilian_wittman/status/999728573324890113
@XMcVey
24 May 2018 20:08
RT @lilian_wittman: #WeNurses I also think that human factors should be taken into account as there is usually a chain of events leading up…
@modopickle
24 May 2018 20:08
#WeNurses A good Patient Safety investigation is one which includes the patient/relatives from the outset to help f… https://twitter.com/i/web/status/999728828586102784
@WeNurses
24 May 2018 20:08
@AlanJCard Hi Alan... thanks for joining from San Diego - great to share our differences and commonalities via #wenurses
@XMcVey
24 May 2018 20:09
@WeNurses Definitely agree with this! My experience of SIs have often not been a ‘simple’ error in isolation #wenurses
@DrUmeshPrabhu
24 May 2018 20:09
RT @NRCUK: Listening in to #wenurses this eve on "Learning from serious incidents" with my safeguarding and quality IT hat on.....
@WeNurses
24 May 2018 20:09
Anyone want to add anything to this? Seems quite comprehensive ? #WeNurses https://twitter.com/JonathanCliffe8/status/999728933145804805
@sue_leddington
24 May 2018 20:09
RT @WeNurses: Tonight at 8pm #WeNurses with @ptsafetyNHS will be discussing Serious Incidents and the Serious Incident Framework ... this i…
@SafetyDonna
24 May 2018 20:09
#wenurses Thanks Jane. We agree that the 'Why' and the application of learning is key https://twitter.com/schoolnurse17/status/999728622410846208
@WeNurses
24 May 2018 20:10
RT @XMcVey: @WeNurses Definitely agree with this! My experience of SIs have often not been a ‘simple’ error in isolation #wenurses
@Lauren_e_Mosley
24 May 2018 20:10
Great to have you with us @LeanneHPatrick its people like you who can change things in the future #WeNurses https://twitter.com/LeanneHPatrick/status/999728859732946954
@samanthaclare
24 May 2018 20:10
I'd love to earwig on this #wenurses as I am sure that there's stuff that library staff can do to help, but I am al… https://twitter.com/i/web/status/999729322108882944
@WeNurses
24 May 2018 20:10
RT @SafetyDonna: #wenurses Thanks Jane. We agree that the 'Why' and the application of learning is key https://twitter.com/schoolnurse17/status/999728622410846208
@AlanJCard
24 May 2018 20:10
@WeNurses Thanks! I first learned about patient safety in the UK, so I'm still very attached. :-) #wenurses
@becksherrington
24 May 2018 20:10
@WeNurses One which starts with a open mind, no conclusions before started. #wenurses
@2soprano
24 May 2018 20:10
@AgencyNurse Objective, open and honest review of the incident #WeNurses
@AgencyNurse
24 May 2018 20:10
@samanthaclare @scaredycait nice to have you drop in ... and yes sure there is a role here #WeNurses
@GwenMoulster
24 May 2018 20:10
RT @WeLDnurses: A really interesting topic for all via #WeNurses Tonight >> https://twitter.com/WeNurses/status/999534969981718529
@becksherrington
24 May 2018 20:11
RT @WeNurses: 10 mins until #WeNurses Tonight we are exploring serious incidents Have a watch of this background video, to find out mor…
@AgencyNurse
24 May 2018 20:11
RT @2soprano: @AgencyNurse Objective, open and honest review of the incident #WeNurses
@JonathanCliffe8
24 May 2018 20:11
Most definitely Teresa, we mustn’t forget this important factor... #WeNurses https://twitter.com/agencynurse/status/999728971402137600
@Lauren_e_Mosley
24 May 2018 20:11
@WeNurses Fab! Yes, so easy to lose vital info when we delay #WeNurses
@AlanJCard
24 May 2018 20:12
@becksherrington @WeNurses Yeah, not like this: https://psnet.ahrq.gov/webmm/case/444 #wenurses
@WeNurses
24 May 2018 20:12
QUESTION 2 is all about what gets in the way ... #WeNurses https://t.co/dn8OCZFEsj
@WeNurses
24 May 2018 20:12
How important do you all feel this is ? How can we achieve this? #WeNurses https://twitter.com/becksherrington/status/999729391373561856
@WeMHNurses
24 May 2018 20:12
Question 2 - what are your thoughts ? #WeNurses https://twitter.com/WeNurses/status/999729754952683520
@GwenMoulster
24 May 2018 20:12
RT @SafetyDonna: #wenurses How can we make this happen https://twitter.com/Lauren_e_Mosley/status/999727700116934656
@Nitchola
24 May 2018 20:12
RT @WeNurses: It's great to have the @ptsafetyNHS team with us this evening - welcome @Lauren_e_Mosley & @SafetyDonna #WeNurses https://t…
@WeLDnurses
24 May 2018 20:12
RT @WeNurses: QUESTION 2 is all about what gets in the way ... #WeNurses https://t.co/dn8OCZFEsj
@WeCYPnurses
24 May 2018 20:12
RT @WeNurses: QUESTION 2 is all about what gets in the way ... #WeNurses https://t.co/dn8OCZFEsj
@GwenMoulster
24 May 2018 20:12
RT @WeNurses: Right now.... We are chatting via #wenurses about "Learning from serious incidents" All welcome.... Just ad #wenurses to you…
@XMcVey
24 May 2018 20:12
RT @WeNurses: QUESTION 2 is all about what gets in the way ... #WeNurses https://t.co/dn8OCZFEsj
@WeMidwives
24 May 2018 20:13
Midwives too .... thoughts ? #WeNurses https://twitter.com/WeNurses/status/999729754952683520
@lilian_wittman
24 May 2018 20:13
#WeNurses @JonathanCliffe8. I absolutely agree - feedback is Italy to understand how the incident occurred. So th… https://twitter.com/i/web/status/999730106108170240
@XMcVey
24 May 2018 20:13
@WeNurses I think people can sometimes be quite fearful and defensive which can slow that process #wenurses
@WeNurses
24 May 2018 20:13
One to read later #WeNurses #EBP https://twitter.com/AlanJCard/status/999729753140572160
@samanthaclare
24 May 2018 20:13
@AgencyNurse @scaredycait I will check back in to the #wenurses chat when I have a moment - will scroll through all the tweets!
@WeNurses
24 May 2018 20:13
RT @XMcVey: @WeNurses I think people can sometimes be quite fearful and defensive which can slow that process #wenurses
@becksherrington
24 May 2018 20:13
@WeNurses Lack of structure to report #wenurses
@WeNurses
24 May 2018 20:13
RT @SafetyDonna: Question 2 People can often describe what a good investigation is so what is preventing this from happening #WeNurses http…
@DeeDavies12
24 May 2018 20:14
@WeNurses Also really important to include the person or families accounts of events and don't forget Duty of Candour #WeNurses
@WeStudentNurse
24 May 2018 20:14
RT @WeNurses: QUESTION 2 is all about what gets in the way ... #WeNurses https://t.co/dn8OCZFEsj
@JonathanCliffe8
24 May 2018 20:14
@PaedCritCareODN @WeNurses External input is very important... #FreshEyes are often needed within a review #WeNurses
@WeNurses
24 May 2018 20:15
Here's a useful diagram from the existing serious incidents framework .... seven key principles #WeNurses https://t.co/ByWQ1ho2PN
@MotherMRuss
24 May 2018 20:15
@WeNurses #WeNurses deviation from our code of conduct.
@becksherrington
24 May 2018 20:15
@WeNurses A culture of blame #wenurses
@lilian_wittman
24 May 2018 20:15
#WeNurses if the people either reporting or investigating have pre conceived ideas about what happened before learning all the facts.
@AgencyNurse
24 May 2018 20:15
Yes THIS >> #WeNurses https://twitter.com/becksherrington/status/999730598813069312
@XMcVey
24 May 2018 20:15
RT @lilian_wittman: #WeNurses if the people either reporting or investigating have pre conceived ideas about what happened before learning…
@WeNurses
24 May 2018 20:15
All great points #WeNurses https://twitter.com/AlanJCard/status/999730605200953344
@XMcVey
24 May 2018 20:16
RT @becksherrington: @WeNurses A culture of blame #wenurses
@XMcVey
24 May 2018 20:16
RT @WeNurses: Here's a useful diagram from the existing serious incidents framework .... seven key principles #WeNurses https://t.co/ByWQ…
@SafetyDonna
24 May 2018 20:16
#wenurses Absolutely! https://twitter.com/DeeDavies12/status/999730251503718400
@WeNurses
24 May 2018 20:16
How do we ensure this doesnt happen ? #WeNurses https://twitter.com/lilian_wittman/status/999730612679389184
@WeNurses
24 May 2018 20:16
Just joining in? We are chatting via #wenurses this eve exploring "Learning from serious incidents" Click on… https://twitter.com/i/web/status/999730830003134465
@WeNurses
24 May 2018 20:16
RT @SafetyDonna: #wenurses Absolutely! https://twitter.com/DeeDavies12/status/999730251503718400
@WeCYPnurses
24 May 2018 20:16
RT @WeNurses: Just joining in? We are chatting via #wenurses this eve exploring "Learning from serious incidents" Click on #wenurses to se…
@RCNOPF
24 May 2018 20:16
RT @WeNurses: Here's a useful diagram from the existing serious incidents framework .... seven key principles #WeNurses https://t.co/ByWQ…
@Jaynebiddiscom1
24 May 2018 20:16
@WeNurses @AgencyNurse @LeanneHPatrick @Lauren_e_Mosley I'm listening in #wenurses
@redmoorhealth
24 May 2018 20:16
@chchambers1 Great work well done! #digitalnurses #wenurses
@Nitchola
24 May 2018 20:16
RT @WeNurses: Just joining in? We are chatting via #wenurses this eve exploring "Learning from serious incidents" Click on #wenurses to se…
@WeSchoolNurses
24 May 2018 20:16
RT @WeNurses: Here's a useful diagram from the existing serious incidents framework .... seven key principles #WeNurses https://t.co/ByWQ…
@GalvanizedRN
24 May 2018 20:17
RT @WeNurses: One to read later #WeNurses #EBP https://twitter.com/AlanJCard/status/999729753140572160
@ptsafetyNHS
24 May 2018 20:17
RT @WeNurses: Just joining in? We are chatting via #wenurses this eve exploring "Learning from serious incidents" Click on #wenurses to se…
@WeNurses
24 May 2018 20:17
@Jaynebiddiscom1 @AgencyNurse @LeanneHPatrick @Lauren_e_Mosley listen away :) #wenurses
@WeMidwives
24 May 2018 20:17
RT @WeNurses: Here's a useful diagram from the existing serious incidents framework .... seven key principles #WeNurses https://t.co/ByWQ…
@WeGPNs
24 May 2018 20:17
RT @WeNurses: Just joining in? We are chatting via #wenurses this eve exploring "Learning from serious incidents" Click on #wenurses to se…
@WeNurses
24 May 2018 20:18
Anyone else find timelines useful ? #WeNurses https://twitter.com/Karleen44968669/status/999731137500073985
@MaryDunningTU
24 May 2018 20:18
@WeNurses Having a supportive culture #WeNurses When things go wrong, people worry, are concerned, are fearful and they need support & care.
@Lauren_e_Mosley
24 May 2018 20:18
@WeNurses Great points! Multiple complex problems #WeNurses
@modopickle
24 May 2018 20:18
@WeNurses #WeNurses Lack of training and use of suitable tools is a big one for me.
@WeNurses
24 May 2018 20:18
RT @modopickle: @WeNurses #WeNurses Lack of training and use of suitable tools is a big one for me.
@lilian_wittman
24 May 2018 20:18
#WeNurses @AlanJCard, the blame culture is something that individuals are very concerned about as it exists in so many workplaces.
@CarrieMaisie
24 May 2018 20:18
RT @WeNurses: Right now.... We are chatting via #wenurses about "Learning from serious incidents" All welcome.... Just ad #wenurses to you…
@XMcVey
24 May 2018 20:19
@WeNurses Yes I think it gives you a good starting point to really understand what was going on that day #wenurses
@AgencyNurse
24 May 2018 20:19
Think that this is an important point #WeNurses https://twitter.com/Jo3_NHS/status/999731406631825408
@AgencyNurse
24 May 2018 20:19
Absolutely #WeNurses https://twitter.com/KatieAnnSiobhan/status/999731481923719168
@nursemaiden
24 May 2018 20:19
Yes we use a chronological time line for all our RCA incidents and other tools, 5 whys, fishbone etc #Wenurses https://twitter.com/wenurses/status/999731275681366016
@BJNursing
24 May 2018 20:19
If I understood the question correctly - fear, shame, pride, ignorance maybe #WeNurses https://twitter.com/wenurses/status/999729754952683520
@Lauren_e_Mosley
24 May 2018 20:20
@CatherinePelley @WeNurses So important and usually the bit that we don't do as well as we'd like #WeNurses
@PhyllisStein2
24 May 2018 20:20
@WeNurses Incomplete data and dishonesty #wenurses
@WeNurses
24 May 2018 20:20
RT @BJNursing: If I understood the question correctly - fear, shame, pride, ignorance maybe #WeNurses https://twitter.com/wenurses/status/999729754952683520
@AlanJCard
24 May 2018 20:20
RT @lilian_wittman: #WeNurses @AlanJCard, the blame culture is something that individuals are very concerned about as it exists in so many…
@4AdsthePoet
24 May 2018 20:20
RT @AgencyNurse: One that ultimately reduces the risk that the same - or similar - doesn't happen again ! #WeNurses https://twitter.com/WeNurses/status/999727248075821057
@modopickle
24 May 2018 20:20
@WeNurses #WeNurses We have a whole industry built around incident reporting that generates the same answers for a… https://twitter.com/i/web/status/999731841673416705
@DeeDavies12
24 May 2018 20:20
@WeNurses #WeNurses On occasions releasing staff from clinical committments - this is so important as we move to pe… https://twitter.com/i/web/status/999731868982444037
@XMcVey
24 May 2018 20:20
RT @BJNursing: If I understood the question correctly - fear, shame, pride, ignorance maybe #WeNurses https://twitter.com/wenurses/status/999729754952683520
@AgencyNurse
24 May 2018 20:20
@BJNursing I think thats a great answer - think that all of these play a role here and we need to be mindful of that #Wenurses
@SafetyDonna
24 May 2018 20:20
There seems to be a lot of knowledge in this group, your views are so valuable. Keep them coming! #wenurses
@tomiteacher
24 May 2018 20:20
RT @WeNurses: QUESTION 2 is all about what gets in the way ... #WeNurses https://t.co/dn8OCZFEsj
@WeNurses
24 May 2018 20:21
Fab #WeNurses https://twitter.com/nursemaiden/status/999731730897661952
@lilian_wittman
24 May 2018 20:21
#WeNurses timelines are definitely helpful as is keeping a personal statement of events if you're directly involved in the incident.
@WeNurses
24 May 2018 20:21
RT @DeeDavies12: @WeNurses #WeNurses On occasions releasing staff from clinical committments - this is so important as we move to peer revi…
@WeNurses
24 May 2018 20:21
#WeNurses https://twitter.com/Trish_McKinney/status/999731991057715210
@Trish_McKinney
24 May 2018 20:21
@WeNurses Fear #Wenurses
@selenam738
24 May 2018 20:21
RT @modopickle: @WeNurses #WeNurses We have a whole industry built around incident reporting that generates the same answers for a lot of i…
@WeNurses
24 May 2018 20:21
What do people think ? #WeNurses https://twitter.com/LeanneHPatrick/status/999732077552685056
@WeNurses
24 May 2018 20:22
#WeNurses https://twitter.com/Karleen44968669/status/999732176269860865
@AlanJCard
24 May 2018 20:22
RT @modopickle: @WeNurses #WeNurses We have a whole industry built around incident reporting that generates the same answers for a lot of i…
@KatieAnnSiobhan
24 May 2018 20:22
@WeNurses #wenurses accountability an transparency, the trust's legal teams go on defensive, the were's blame is a… https://twitter.com/i/web/status/999732287326572546
@MaryDunningTU
24 May 2018 20:22
@SafetyDonna @WeNurses #WeNurses It would be good to hear more about the good investigations, we need people who ar… https://twitter.com/i/web/status/999732419149336577
@Ruthiemccarroll
24 May 2018 20:22
@WeCYPnurses Follow patient journey from start to finish carefully and methodically #wenurses
@AgencyNurse
24 May 2018 20:22
Oooh important point here I feel #WeNurses https://twitter.com/CatherinePelley/status/999732070262943746
@AgencyNurse
24 May 2018 20:22
RT @lilian_wittman: #WeNurses timelines are definitely helpful as is keeping a personal statement of events if you're directly involved in…
@WeNurses
24 May 2018 20:22
RT @lilian_wittman: #WeNurses timelines are definitely helpful as is keeping a personal statement of events if you're directly involved in…
@AlanJCard
24 May 2018 20:23
@modopickle @WeNurses Yup! Have you read "The Problem with Incident Reporting?" - http://qualitysafety.bmj.com/content/25/2/71 Excellent piece of work. #WeNurses
@Lyse_e
24 May 2018 20:23
RT @WeNurses: Here's a useful diagram from the existing serious incidents framework .... seven key principles #WeNurses https://t.co/ByWQ…
@Lauren_e_Mosley
24 May 2018 20:23
I'd agree. The focus seems to be on declaring and writing the report and not on what happens afterwards #WeNurses https://twitter.com/modopickle/status/999731841673416705
@WeNurses
24 May 2018 20:23
Excellent point - how could we ensure this happened ? #WeNurses https://twitter.com/MaryDunningTU/status/999732419149336577
@AgencyNurse
24 May 2018 20:24
@becksherrington yes i see your point - perhaps the two are intertwined ? #WeNurses
@WeStudentNurse
24 May 2018 20:24
RT @BJNursing: If I understood the question correctly - fear, shame, pride, ignorance maybe #WeNurses https://twitter.com/wenurses/status/999729754952683520
@DrUmeshPrabhu
24 May 2018 20:24
RT @WeNurses: QUESTION 2 is all about what gets in the way ... #WeNurses https://t.co/dn8OCZFEsj
@IPenfold
24 May 2018 20:24
RT @WeNurses: 10 mins until #WeNurses Tonight we are exploring serious incidents Have a watch of this background video, to find out mor…
@JerseycapP
24 May 2018 20:24
Protected time and appropriate training is critical #WeNurses
@SafetyDonna
24 May 2018 20:24
#wenurses Hi Alan, I'm not sure we do half enough cross-setting investigations, so this is a great point ... https://twitter.com/AlanJCard/status/999732113866969088
@WeNurses
24 May 2018 20:24
thanks for sharing #ebp #wenurses https://twitter.com/AlanJCard/status/999732548308750337
@WeNurses
24 May 2018 20:24
RT @SafetyDonna: #wenurses Hi Alan, I'm not sure we do half enough cross-setting investigations, so this is a great point ... https://t.co/…
@WeLDnurses
24 May 2018 20:24
RT @SafetyDonna: #wenurses Hi Alan, I'm not sure we do half enough cross-setting investigations, so this is a great point ... https://t.co/…
@WeCYPnurses
24 May 2018 20:25
RT @SafetyDonna: #wenurses Hi Alan, I'm not sure we do half enough cross-setting investigations, so this is a great point ... https://t.co/…
@WeNurses
24 May 2018 20:25
Here's QUESTION 3 - what should we do better to support staff ?? #WeNurses https://t.co/ljg1H8AT8b
@DrUmeshPrabhu
24 May 2018 20:25
RT @modopickle: @WeNurses #WeNurses We have a whole industry built around incident reporting that generates the same answers for a lot of i…
@WeStudentNurse
24 May 2018 20:25
RT @WeNurses: Here's a useful diagram from the existing serious incidents framework .... seven key principles #WeNurses https://t.co/ByWQ…
@DrUmeshPrabhu
24 May 2018 20:25
@modopickle @WeNurses Well said #WeNurses
@DrUmeshPrabhu
24 May 2018 20:25
RT @DeeDavies12: @WeNurses #WeNurses On occasions releasing staff from clinical committments - this is so important as we move to peer revi…
@WeDistrictNurse
24 May 2018 20:25
RT @WeNurses: Here's QUESTION 3 - what should we do better to support staff ?? #WeNurses https://t.co/ljg1H8AT8b
@WeCYPnurses
24 May 2018 20:25
RT @WeNurses: Here's QUESTION 3 - what should we do better to support staff ?? #WeNurses https://t.co/ljg1H8AT8b
@WeSchoolNurses
24 May 2018 20:25
RT @WeNurses: Here's QUESTION 3 - what should we do better to support staff ?? #WeNurses https://t.co/ljg1H8AT8b
@WeLDnurses
24 May 2018 20:25
RT @WeNurses: Here's QUESTION 3 - what should we do better to support staff ?? #WeNurses https://t.co/ljg1H8AT8b
@KatieAnnSiobhan
24 May 2018 20:25
@lilian_wittman #wenurses failure in communication has been cropping up again and again throughout my brother's ser… https://t.co/l6DeaPiBUl
@Ruthiemccarroll
24 May 2018 20:25
@WeNurses Lack of objectivity due to fear of blame, guilt, investigator not neutral #wenurses
@AlanJCard
24 May 2018 20:26
Why I strongly recommend *against* using '5 whys' https://tinyurl.com/5WhysProblem #wenurses
@WeStudentNurse
24 May 2018 20:26
RT @WeNurses: Here's QUESTION 3 - what should we do better to support staff ?? #WeNurses https://t.co/ljg1H8AT8b
@MaryDunningTU
24 May 2018 20:26
@lilian_wittman @WeNurses #WeNurses I also think reflecting is useful as it can help you consider the factual infor… https://twitter.com/i/web/status/999733318731075586
@becksherrington
24 May 2018 20:26
@FrancesHealey I'd absolutely agree - blaming other within team too #WeNurses
@bjgw
24 May 2018 20:26
@WeNurses Lack of knowledge of process by the investigator#wenurses
@AlanJCard
24 May 2018 20:26
RT @SafetyDonna: #wenurses Hi Alan, I'm not sure we do half enough cross-setting investigations, so this is a great point ... https://t.co/…
@WeNurses
24 May 2018 20:26
RT @MaryDunningTU: @lilian_wittman @WeNurses #WeNurses I also think reflecting is useful as it can help you consider the factual informatio…
@sarah_janemad
24 May 2018 20:27
RT @WeNurses: Hello and welcome to #WeNurses Please tweet us a hello if you are joining us this evening to discuss "Serious Incidents" ht…
@WeMidwives
24 May 2018 20:27
What more could we do to support staff ? #WeNurses https://t.co/QkWvP8q7dk
@WeLDnurses
24 May 2018 20:27
Question 3 #WeNurses https://t.co/Oes45bPqXm
@WeNurses
24 May 2018 20:27
Anybody else think blame is definitely going to be tonights #wenurses chat cloud? Wonder how other sectors have add… https://t.co/ePxkDNrgpR
@NRCUK
24 May 2018 20:27
RT @WeNurses: Anybody else think blame is definitely going to be tonights #wenurses chat cloud? Wonder how other sectors have addressed thi…
@modopickle
24 May 2018 20:27
@Gemma_Louch @WeNurses @LeanneHPatrick @YH_PSTRC #WeNurses There are some great projects undertaken by @YH_PSTRC I’… https://t.co/eqRXHgGWGQ
@nursemaiden
24 May 2018 20:28
RT @AlanJCard: Why I strongly recommend *against* using '5 whys' https://t.co/rHkXnjpDmA #wenurses
@sarah_janemad
24 May 2018 20:28
RT @MaryDunningTU: @lilian_wittman @WeNurses #WeNurses I also think reflecting is useful as it can help you consider the factual informatio…
@DrUmeshPrabhu
24 May 2018 20:28
RT @MaryDunningTU: @lilian_wittman @WeNurses #WeNurses I also think reflecting is useful as it can help you consider the factual informatio…
@WeCYPnurses
24 May 2018 20:28
What do you think ? Vote here #WeNurses https://t.co/JyfYh3IWIw
@WeLDnurses
24 May 2018 20:28
Poll Tweet here #WeNurses https://t.co/PeltHAO4s3
@sarah_janemad
24 May 2018 20:28
RT @WeNurses: Here's QUESTION 3 - what should we do better to support staff ?? #WeNurses https://t.co/ljg1H8AT8b
@WeMHNurses
24 May 2018 20:28
Share your views via this poll #WeNurses https://t.co/OhfSQGmR3H
@selenam738
24 May 2018 20:29
#wenurses with more Human Factors awareness and training, improvements abound in all aspects of investigation, feedback, learning.
@nursemaiden
24 May 2018 20:29
RT @WeNurses: Anybody else think blame is definitely going to be tonights #wenurses chat cloud? Wonder how other sectors have addressed thi…
@modopickle
24 May 2018 20:29
@AlanJCard @WeNurses #WeNurses Yes I have. Currently listening to The Safety Anarchist by @sidneydekkercom, well worth a read/listen.
@Lauren_e_Mosley
24 May 2018 20:29
Yes so important to look at the system and the conditions staff are working in #WeNurses https://twitter.com/DrUmeshPrabhu/status/999733688643579906
@bjgw
24 May 2018 20:29
@Lauren_e_Mosley An open culture that is willing to accept and deal with the results of investigations #wenurses
@becksherrington
24 May 2018 20:29
@WeLDnurses How have others done this? Love to know #Wenurses
@janekohara
24 May 2018 20:29
@WeNurses Hello! A little late, but here ?? #wenurses
@AgencyNurse
24 May 2018 20:29
I think that this is a great answer #WeNurses We need to be compassionate but at the same time fair and just… https://twitter.com/i/web/status/999734268472582145
@WeNurses
24 May 2018 20:30
This sounds like a good idea ... anywhere else do this ? #WeNurses https://twitter.com/CatherinePelley/status/999734105347690497
@WeNurses
24 May 2018 20:30
RT @selenam738: #wenurses with more Human Factors awareness and training, improvements abound in all aspects of investigation, feedback, le…
@MaryDunningTU
24 May 2018 20:30
@WeNurses Is it blame? or is it being fair? I think intention & motivation are considerations. #WeNurses
@modopickle
24 May 2018 20:30
RT @Lauren_e_Mosley: I'd agree. The focus seems to be on declaring and writing the report and not on what happens afterwards #WeNurses http…
@WeNurses
24 May 2018 20:30
#WeNurses https://twitter.com/Laconic_doc/status/999734358306181120
@LeanneHPatrick
24 May 2018 20:31
RT @WeNurses: Anybody else think blame is definitely going to be tonights #wenurses chat cloud? Wonder how other sectors have addressed thi…
@WeNurses
24 May 2018 20:31
RT @MaryDunningTU: @WeNurses Is it blame? or is it being fair? I think intention & motivation are considerations. #WeNurses
@WeNurses
24 May 2018 20:31
Nice point #WeNurses https://twitter.com/bjgw/status/999734190190026752
@KatieAnnSiobhan
24 May 2018 20:31
@WeNurses #wenurses #time and #resources
@WeNurses
24 May 2018 20:31
#WeNurses https://twitter.com/tamsingradford/status/999734612963323904
@AlanJCard
24 May 2018 20:31
RT @modopickle: @AlanJCard @WeNurses #WeNurses Yes I have. Currently listening to The Safety Anarchist by @sidneydekkercom, well worth a re…
@bjgw
24 May 2018 20:31
@WeCYPnurses A lot better than we used to #WeNurses
@MarySextonNHS
24 May 2018 20:31
@WeNurses #WeNurses Recognise and acknowledge the impact to them at personal level of being involved in an SI. Ensu… https://twitter.com/i/web/status/999734775576481792
@Ruthiemccarroll
24 May 2018 20:32
@WeNurses Remember that staff can feel incredibly stressed by whole process and often leads to sickness and absence #WeNurses
@sarah_janemad
24 May 2018 20:32
RT @WeNurses: thanks for sharing #ebp #wenurses https://twitter.com/AlanJCard/status/999732548308750337
@WeNurses
24 May 2018 20:32
#WeNurses - anyone else come across this? #WeNurses https://twitter.com/Jaynebiddiscom1/status/999734643413934081
@DrUmeshPrabhu
24 May 2018 20:32
RT @AgencyNurse: I think that this is a great answer #WeNurses We need to be compassionate but at the same time fair and just #WeNurses h…
@WeStudentNurse
24 May 2018 20:32
RT @WeNurses: Anybody else think blame is definitely going to be tonights #wenurses chat cloud? Wonder how other sectors have addressed thi…
@NRCUK
24 May 2018 20:32
interesting tweetchat on now @DanielBayley80 @kennygibsonnhs on Learning from serious incidents via #wenurses if you are about...
@sarah_janemad
24 May 2018 20:32
RT @SafetyDonna: #wenurses Hi Alan, I'm not sure we do half enough cross-setting investigations, so this is a great point ... https://t.co/…
@katblossom
24 May 2018 20:32
RT @WeNurses: Here's QUESTION 3 - what should we do better to support staff ?? #WeNurses https://t.co/ljg1H8AT8b
@sarah_janemad
24 May 2018 20:32
RT @WeNurses: Excellent point - how could we ensure this happened ? #WeNurses https://twitter.com/MaryDunningTU/status/999732419149336577
@becksherrington
24 May 2018 20:33
@JerseycapP #Wenurses how have others encouraged teams in clinical areas to get involved?
@Ruthiemccarroll
24 May 2018 20:33
@sarah_janemad @WeNurses Such an important point #systemerrors #wenurses
@XMcVey
24 May 2018 20:33
@JonathanCliffe8 Yes I’m a bit advocate for clinical supervision. Trying to introduce it into my area of work at the minute #WeNurses
@AlanJCard
24 May 2018 20:33
A lot of great reflection on these problems in "The Problem with Root Cause Analysis" http://qualitysafety.bmj.com/content/qhc/early/2016/06/23/bmjqs-2016-005511.full.pdf #wenurses
@WeNurses
24 May 2018 20:33
@NRCUK @DanielBayley80 @kennygibsonnhs thanks for sharing :) #wenurses
@PhyllisStein2
24 May 2018 20:33
@NRCUK @WeNurses Access to data department know where everything is-ask them. If they can't find it it has been put in the bin. #wenurses
@AgencyNurse
24 May 2018 20:33
Really important point - support is key for both staff and families #WeNurses https://twitter.com/Ruthiemccarroll/status/999734792131436545
@BJNursing
24 May 2018 20:34
#WeNurses I think nurses or those being ‘investigated’ should be provided with good counsel provided by the organi… https://twitter.com/i/web/status/999735316306014208
@WeNurses
24 May 2018 20:34
#WeNurses https://twitter.com/KatieAnnSiobhan/status/999735229169520641
@WeNurses
24 May 2018 20:34
absolutely #WeNurses https://twitter.com/becksherrington/status/999735223368798209
@WeNurses
24 May 2018 20:34
RT @BJNursing: #WeNurses I think nurses or those being ‘investigated’ should be provided with good counsel provided by the organisation -…
@Lauren_e_Mosley
24 May 2018 20:34
@bjgw @WeCYPnurses Its good to think about the progress made so far #WeNurses
@XMcVey
24 May 2018 20:34
RT @BJNursing: #WeNurses I think nurses or those being ‘investigated’ should be provided with good counsel provided by the organisation -…
@sarah_janemad
24 May 2018 20:35
@MaryDunningTU @WeNurses Compl agree but they need to be role modelled from senior staff too & championed openly #WeNurses
@janekohara
24 May 2018 20:35
Apologies! Out of practice... Now with the hashtag #wenurses https://twitter.com/janekohara/status/999735141676322817
@WeNurses
24 May 2018 20:35
RT @janekohara: Apologies! Out of practice... Now with the hashtag #wenurses https://twitter.com/janekohara/status/999735141676322817
@PhyllisStein2
24 May 2018 20:35
RT @WeNurses: #WeNurses - anyone else come across this? #WeNurses https://twitter.com/Jaynebiddiscom1/status/999734643413934081
@modopickle
24 May 2018 20:35
#WeNurses The works by Susan D Scott on Second Victims is well worth reading. I know some do not like the term but… https://twitter.com/i/web/status/999735676026478593
@sarah_janemad
24 May 2018 20:35
RT @BJNursing: #WeNurses I think nurses or those being ‘investigated’ should be provided with good counsel provided by the organisation -…
@sarah_janemad
24 May 2018 20:35
RT @AlanJCard: A lot of great reflection on these problems in "The Problem with Root Cause Analysis" http://qualitysafety.bmj.com/content/qhc/early/2016/06/23/bmjqs-2016-005511.full.pdf #wenurses
@DrUmeshPrabhu
24 May 2018 20:36
@KatieAnnSiobhan @WeNurses #Communication communication communication. Honesty honesty honesty. Open and transparent always #WeNurses
@WeNurses
24 May 2018 20:36
@janekohara no apologies needed :D #WeNurses
@AlanJCard
24 May 2018 20:36
RT @WeNurses: #WeNurses - anyone else come across this? #WeNurses https://twitter.com/Jaynebiddiscom1/status/999734643413934081
@nursemaiden
24 May 2018 20:36
Anyone use the positive incident management reporting process in their organisations #Wenurses https://twitter.com/jonathancliffe8/status/999735518412902400
@MaryDunningTU
24 May 2018 20:37
@sarah_janemad @WeNurses #WeNurses Yes, Lead by example!
@WeNurses
24 May 2018 20:37
QUESTION 4 asks about resources ... #WeNurses https://t.co/13PXzi1j1K
@WeNurses
24 May 2018 20:37
Thoughts on second victims ? #WeNurses https://twitter.com/modopickle/status/999735676026478593
@SafetyDonna
24 May 2018 20:37
#wenurses great point! https://twitter.com/modopickle/status/999735676026478593
@WeStudentNurse
24 May 2018 20:37
RT @WeNurses: QUESTION 4 asks about resources ... #WeNurses https://t.co/13PXzi1j1K
@becksherrington
24 May 2018 20:37
@WeNurses ??I wonder if any studies asked pts views? #wenurses
@JonathanCliffe8
24 May 2018 20:37
I agree #WeNurses https://twitter.com/agencynurse/status/999735834072010752
@WeCYPnurses
24 May 2018 20:37
Question 4 is here folks #WeNurses https://twitter.com/WeNurses/status/999736045334859776
@Lauren_e_Mosley
24 May 2018 20:37
#wenurses Patients, carers and staff are often the people who have the most comprehensive picture of what happened… https://twitter.com/i/web/status/999736188192817153
@WeLDnurses
24 May 2018 20:37
RT @WeNurses: QUESTION 4 asks about resources ... #WeNurses https://t.co/13PXzi1j1K
@WeNurses
24 May 2018 20:37
@DrUmeshPrabhu @KatieAnnSiobhan and how we do make this happen... sounds great! You've lots of experience to share :) #wenurses
@WeMHNurses
24 May 2018 20:37
RT @WeNurses: QUESTION 4 asks about resources ... #WeNurses https://t.co/13PXzi1j1K
@WeMidwives
24 May 2018 20:37
RT @WeNurses: QUESTION 4 asks about resources ... #WeNurses https://t.co/13PXzi1j1K
@WeSchoolNurses
24 May 2018 20:37
RT @WeCYPnurses: Question 4 is here folks #WeNurses https://twitter.com/WeNurses/status/999736045334859776
@JonathanCliffe8
24 May 2018 20:37
@nursemaiden I’d be interested to hear more Sally #WeNurses
@WeNurses
24 May 2018 20:38
Anyone know of any ? #WeNurses https://twitter.com/becksherrington/status/999736148552536064
@selenam738
24 May 2018 20:38
@nursemaiden No....but we should! Is it called Greatix? #wenurses
@JerseycapP
24 May 2018 20:38
Think it’s really important that staff feel supported and it is recognized the crisis of confidence staff can face #WeNurses
@MaryDixonWoods
24 May 2018 20:38
RT @AlanJCard: A lot of great reflection on these problems in "The Problem with Root Cause Analysis" http://qualitysafety.bmj.com/content/qhc/early/2016/06/23/bmjqs-2016-005511.full.pdf #wenurses
@DrUmeshPrabhu
24 May 2018 20:38
RT @WeNurses: QUESTION 4 asks about resources ... #WeNurses https://t.co/13PXzi1j1K
@AgencyNurse
24 May 2018 20:38
@JonathanCliffe8 must be the hardest things to share though .... as it's ultimately talking about what went wrong #WeNurses
@BJNursing
24 May 2018 20:38
#WeNurses ‘investigations’ should be consistent in their approach and resources used should be fit for purpose and… https://twitter.com/i/web/status/999736525867888641
@janekohara
24 May 2018 20:39
@WeNurses Start by accepting there is unlikely to be a "root cause" to an error. #wenurses
@WeNurses
24 May 2018 20:39
Great to hear #WeNurses https://twitter.com/bjgw/status/999736065735974914
@DrUmeshPrabhu
24 May 2018 20:39
@WeNurses @KatieAnnSiobhan This is two hours lecture #WeNurses
@SafetyDonna
24 May 2018 20:39
#WeNurses Conducting fewer investigations is one way of freeing up resources to allow more in-depth investigations… https://t.co/qkbpOtDGYw
@WeNurses
24 May 2018 20:39
An important point raised here ... how can we avoid this ? #WeNurses https://t.co/aSckXtwnkE
@bjgw
24 May 2018 20:39
Standardisation of process but esp paperwork #WeNurses https://t.co/UOVqoBXFkw
@TVN_UHCW
24 May 2018 20:39
RT @WeNurses: Here's a useful diagram from the existing serious incidents framework .... seven key principles #WeNurses https://t.co/ByWQ…
@WeNurses
24 May 2018 20:39
@DrUmeshPrabhu @KatieAnnSiobhan any online resources to share? #wenurses
@TVN_UHCW
24 May 2018 20:40
RT @modopickle: @WeNurses #WeNurses We have a whole industry built around incident reporting that generates the same answers for a lot of i…
@TVN_UHCW
24 May 2018 20:40
RT @AgencyNurse: One that ultimately reduces the risk that the same - or similar - doesn't happen again ! #WeNurses https://twitter.com/WeNurses/status/999727248075821057
@WeNurses
24 May 2018 20:40
A reminder some elements of the current serious incident framework for you all #WeNurses https://t.co/RjOqhnPz37
@TVN_UHCW
24 May 2018 20:40
RT @lilian_wittman: #WeNurses hi guys Lilian saying hello ??. The people conducting the investigation must be impartial and non judgemental…
@ashtullett
24 May 2018 20:40
@WeNurses TIME - A good investigation is a long process and requires protected time and resource. #WeNurses
@WeNurses
24 May 2018 20:40
#WeNurses https://twitter.com/derekfisher2907/status/999736948980842496
@lilian_wittman
24 May 2018 20:40
#WeNurses @MaryDunningTU I would use the "blame" word as in my experience judgements are made before the investigat… https://twitter.com/i/web/status/999737026357362688
@WeNurses
24 May 2018 20:41
RT @ashtullett: @WeNurses TIME - A good investigation is a long process and requires protected time and resource. #WeNurses
@DrUmeshPrabhu
24 May 2018 20:41
@WeNurses @KatieAnnSiobhan Just about to publish few articles and book #WeNurses Family first and staff next and ev… https://twitter.com/i/web/status/999737056799666176
@DrUmeshPrabhu
24 May 2018 20:41
RT @WeNurses: @DrUmeshPrabhu @KatieAnnSiobhan any online resources to share? #wenurses
@Lauren_e_Mosley
24 May 2018 20:41
@janekohara @WeNurses Very interesting - sometimes 'RCA' is misunderstood and people think this is looking for ONE root cause only #WeNurses
@AgencyNurse
24 May 2018 20:41
Or wider even ! could this be a role for case studies ?? #WeNurses https://twitter.com/becksherrington/status/999736994648543232
@sarah_janemad
24 May 2018 20:41
RT @WeNurses: A reminder some elements of the current serious incident framework for you all #WeNurses https://t.co/RjOqhnPz37
@AlanJCard
24 May 2018 20:41
@Gemma_Louch It is! I'm always going back to it. #wenurses
@WeNurses
24 May 2018 20:41
#WeNurses https://twitter.com/ashleyluchmun/status/999737197963202560
@becksherrington
24 May 2018 20:42
@bjgw @RBCH_NHS How to u share the learning throughout your organisation? #Wenurses
@WeNurses
24 May 2018 20:42
RT @janekohara: @WeNurses Start by accepting there is unlikely to be a "root cause" to an error. #wenurses
@nursemaiden
24 May 2018 20:42
RT @selenam738: @nursemaiden No....but we should! Is it called Greatix? #wenurses
@sheffnurse
24 May 2018 20:42
RT @WeNurses: QUESTION 2 is all about what gets in the way ... #WeNurses https://t.co/dn8OCZFEsj
@WeNurses
24 May 2018 20:42
Interesting point ... could we conduct fewer investigations? #WeNurses https://twitter.com/SafetyDonna/status/999736750858801152
@MrsEmmaJK
24 May 2018 20:42
RT @WeNurses: #WeNurses https://twitter.com/derekfisher2907/status/999736948980842496
@MarkCourtney10
24 May 2018 20:43
RT @AlanJCard: A lot of great reflection on these problems in "The Problem with Root Cause Analysis" http://qualitysafety.bmj.com/content/qhc/early/2016/06/23/bmjqs-2016-005511.full.pdf #wenurses
@modopickle
24 May 2018 20:43
#wenurses quote from Sir Robert Francis QC from a lecture this week, so very true.... https://twitter.com/modopickle/status/998515672169762816
@MaryDunningTU
24 May 2018 20:44
@FrancesHealey @WeNurses #WeNurses I think self-blame is a factor, I think knowing how to be part of a 'constructiv… https://twitter.com/i/web/status/999737849921638401
@NRCUK
24 May 2018 20:44
@ashtullett @WeNurses interesting.... are long processes a sign of lack of efficiency or priority? #wenurses
@selenam738
24 May 2018 20:44
RT @modopickle: #wenurses quote from Sir Robert Francis QC from a lecture this week, so very true.... https://twitter.com/modopickle/status/998515672169762816
@nursemaiden
24 May 2018 20:44
RT @modopickle: #wenurses quote from Sir Robert Francis QC from a lecture this week, so very true.... https://twitter.com/modopickle/status/998515672169762816
@Nitchola
24 May 2018 20:44
@NRCUK @CatherinePelley @WeNurses There are definitely opportunities to reduce duplication across the system #WeNurses
@WeNurses
24 May 2018 20:45
#WeNurses https://twitter.com/Laconic_doc/status/999737905374486535
@TVN_UHCW
24 May 2018 20:45
RT @MaryDunningTU: @lilian_wittman @WeNurses #WeNurses I also think reflecting is useful as it can help you consider the factual informatio…
@WeNurses
24 May 2018 20:45
Really important point here #WeNurses https://twitter.com/4AdsthePoet/status/999738012887109633
@WeNurses
24 May 2018 20:45
RT @bjgw: Standardisation of process but esp paperwork #WeNurses https://twitter.com/wenurses/status/999736045334859776
@Lauren_e_Mosley
24 May 2018 20:45
@SafetyDonna Do we always investigate for learning or because we're following a 'must do' SI list? #WeNurses
@sarah_janemad
24 May 2018 20:45
@nursemaiden #WeNurses ???????? https://t.co/Q8cI31OCmb
@AlanJCard
24 May 2018 20:45
RT @SafetyDonna: #WeNurses Conducting fewer investigations is one way of freeing up resources to allow more in-depth investigations that i…
@WeMidwives
24 May 2018 20:45
RT @WeNurses: A reminder some elements of the current serious incident framework for you all #WeNurses https://t.co/RjOqhnPz37
@helenf28
24 May 2018 20:45
RT @modopickle: @WeNurses #WeNurses We have a whole industry built around incident reporting that generates the same answers for a lot of i…
@WeLDnurses
24 May 2018 20:45
RT @WeNurses: A reminder some elements of the current serious incident framework for you all #WeNurses https://t.co/RjOqhnPz37
@WeCYPnurses
24 May 2018 20:46
RT @WeNurses: A reminder some elements of the current serious incident framework for you all #WeNurses https://t.co/RjOqhnPz37
@sheffnurse
24 May 2018 20:46
RT @WeNurses: A reminder some elements of the current serious incident framework for you all #WeNurses https://t.co/RjOqhnPz37
@WeMHNurses
24 May 2018 20:46
RT @WeNurses: A reminder some elements of the current serious incident framework for you all #WeNurses https://t.co/RjOqhnPz37
@NRCUK
24 May 2018 20:46
@bjgw @becksherrington @RBCH_NHS Is there any evidence that the sharing is effective? #wenurses
@janekohara
24 May 2018 20:46
More accident analysis and less one off incidents investigated - YES! #wenurses https://twitter.com/AlanJCard/status/999738139802525698
@nursemaiden
24 May 2018 20:46
RT @sarah_janemad: @nursemaiden #WeNurses ???????? https://t.co/Q8cI31OCmb
@AlanJCard
24 May 2018 20:46
RT @janekohara: @WeNurses Start by accepting there is unlikely to be a "root cause" to an error. #wenurses
@SafetyDonna
24 May 2018 20:46
#wenurses Some people worry that families will need us to investigate every single incident. But do we need to do t… https://t.co/GkByYrEDWj
@Ruthiemccarroll
24 May 2018 20:47
@janekohara @WeNurses More common small process errors and add some human error - all aligns to cause big error #wenurses
@AgencyNurse
24 May 2018 20:47
Wow really ??? #WeNurses https://t.co/ONPZLbLnYo
@AgencyNurse
24 May 2018 20:47
RT @SafetyDonna: #wenurses Some people worry that families will need us to investigate every single incident. But do we need to do that if…
@DrUmeshPrabhu
24 May 2018 20:47
RT @AgencyNurse: Wow really ??? #WeNurses https://t.co/ONPZLbLnYo
@4AdsthePoet
24 May 2018 20:47
@WeNurses Perhaps have fewer events that then need investigating? #Wenurses
@WeNurses
24 May 2018 20:47
Thoughts ? #WeNurses https://t.co/igJvbN2u9c
@TVN_UHCW
24 May 2018 20:47
RT @JerseycapP: Protected time and appropriate training is critical #WeNurses
@AlanJCard
24 May 2018 20:48
RT @janekohara: More accident analysis and less one off incidents investigated - YES! #wenurses https://t.co/DSztoArX5C
@DrUmeshPrabhu
24 May 2018 20:48
@KatieAnnSiobhan @WeNurses So proud of you #WeNurses
@AgencyNurse
24 May 2018 20:48
@SafetyDonna who decides what we investigate ? Could see this being problematic tbh #WeNurses
@PhyllisStein2
24 May 2018 20:48
@WeNurses @SafetyDonna Learning from other places' investigations. National learning and change to keep incidents down #WeNurses
@becksherrington
24 May 2018 20:48
@bjgw @RBCH_NHS Who sees that? #Wenurses
@WeNurses
24 May 2018 20:48
What do you think everyone ... do we investigate for learning ? #WeNurses https://t.co/0TTE1HtagP
@janekohara
24 May 2018 20:48
@4AdsthePoet @WeNurses Yes! But how to decide which ones to investigate is then the tricky bit... #wenurses
@SafetyDonna
24 May 2018 20:48
#wenurses I agree Nichola. How might we avoid duplication when the aims are the same? https://t.co/l5EhgKsBGI
@TVN_UHCW
24 May 2018 20:49
RT @SafetyDonna: #WeNurses Conducting fewer investigations is one way of freeing up resources to allow more in-depth investigations that i…
@Lauren_e_Mosley
24 May 2018 20:49
RT @SafetyDonna: #wenurses Some people worry that families will need us to investigate every single incident. But do we need to do that if…
@Ruthiemccarroll
24 May 2018 20:49
@LivPsy @WeNurses Ha this popped up in the middle of this discussion and quite true! #wenurses
@SafetyDonna
24 May 2018 20:49
#wenurses Absolutely https://t.co/Vjlt38wlCW
@WeNurses
24 May 2018 20:50
Anyone else feel Scwartz rounds are pertinent here ? #WeNurses https://t.co/jDutK4ulSr
@WeNurses
24 May 2018 20:50
RT @SafetyDonna: #wenurses Absolutely https://t.co/Vjlt38wlCW
@MaryDunningTU
24 May 2018 20:50
@Gemma_Louch @LeanneHPatrick @WeNurses @YH_PSTRC #WeNurses Perhaps a menu of choice of how a person wants to be involved
@NRCUK
24 May 2018 20:50
excellent #wenurses https://t.co/WVZoClssjf
@lilian_wittman
24 May 2018 20:50
#WeNurses @bjgw, I think that it's always good to have people involved who have a working knowledge of the area whe… https://t.co/ND1T8h1OLc
@PhyllisStein2
24 May 2018 20:50
RT @WeNurses: Really important point here #WeNurses https://t.co/l3LeFBHpZJ
@WeNurses
24 May 2018 20:51
Are you ready for QUESTION 5 ? Its all about changes ... #WeNurses https://t.co/A1oQbProo9
@AgencyNurse
24 May 2018 20:51
THIS #WeNurses https://t.co/EW3TwswJ40
@WeCYPnurses
24 May 2018 20:51
Question 5 #WeNurses https://t.co/C1mwxC0NMd
@WeLDnurses
24 May 2018 20:51
Question 5 is here >>> #WeNurses https://t.co/T1FMG6Vr0C
@nursemaiden
24 May 2018 20:51
What about all the near misses? One day could be catastrophic? #Wenurses https://t.co/LcymsuQUeA
@WeStudentNurse
24 May 2018 20:51
RT @WeNurses: Are you ready for QUESTION 5 ? Its all about changes ... #WeNurses https://t.co/A1oQbProo9
@WeMidwives
24 May 2018 20:51
Thoughts ? #WeNurses https://t.co/s3VGpCUZzY
@modopickle
24 May 2018 20:51
@AgencyNurse @SafetyDonna #wenurses with proper disclosure perhaps we could be freed to focus on the moderate and s… https://t.co/mUkv1OJUlJ
@NRCUK
24 May 2018 20:51
#wenurses https://t.co/tBEaHw5oqH
@bjgw
24 May 2018 20:52
@DrUmeshPrabhu @AgencyNurse Thanks for that I thought I was the only one! #WeNurses
@MaryDunningTU
24 May 2018 20:52
@lilian_wittman #WeNurses Need to be able to make considered evidence based decisions
@WeNurses
24 May 2018 20:52
#WeNurses >> https://t.co/jYJXtRKTxo
@4AdsthePoet
24 May 2018 20:52
RT @SafetyDonna: #wenurses Absolutely https://t.co/Vjlt38wlCW
@sheffnurse
24 May 2018 20:53
RT @sarah_janemad: @nursemaiden #WeNurses ???????? https://t.co/Q8cI31OCmb
@PaedCritCareODN
24 May 2018 20:53
RT @AgencyNurse: THIS #WeNurses https://twitter.com/sarah_janemad/status/999738255519121408
@WeNurses
24 May 2018 20:54
We've another #wenurses poll coming up... have you all answered this one first please :) https://twitter.com/WeNurses/status/999733481910538240
@sheffnurse
24 May 2018 20:54
RT @WeNurses: Are you ready for QUESTION 5 ? Its all about changes ... #WeNurses https://t.co/A1oQbProo9
@DeeDavies12
24 May 2018 20:55
@WeNurses Any learning should then feed into mandatory training and education days for staff #WeNurses
@NRCUK
24 May 2018 20:55
how would it not :) #wenurses https://twitter.com/Nitchola/status/999740474322767872
@sheffnurse
24 May 2018 20:55
RT @modopickle: @AgencyNurse @SafetyDonna #wenurses with proper disclosure perhaps we could be freed to focus on the moderate and severe??…
@PhyllisStein2
24 May 2018 20:55
@nursemaiden Agree Sally and minor in one situation eg x10 drugs error in one situation may be fatal in another @AgencyNurse #wenurses
@WeCYPnurses
24 May 2018 20:55
Another poll tweet for you #WeNurses https://twitter.com/WeNurses/status/999740721396617217
@Ruthiemccarroll
24 May 2018 20:56
@WeNurses Oh different in wales where we don't have separate commissioners! #wenurses
@modopickle
24 May 2018 20:56
@Nitchola @WeNurses #wenurses I still find it incredible this does not happen robustly.
@WeLDnurses
24 May 2018 20:56
Poll tweet here #WeNurses https://twitter.com/WeNurses/status/999740721396617217
@Lauren_e_Mosley
24 May 2018 20:56
@Nitchola @WeNurses What is your experience of the oversight process @Nitchola ? #WeNurses
@KatieAnnSiobhan
24 May 2018 20:56
@MaryDunningTU @lilian_wittman @WeNurses #wenurses us family members we to reflect on in case of my brother Tim I a… https://t.co/nhYhVipOfS
@bjgw
24 May 2018 20:56
@selenam738 @PointofCareFdn Agree #WeNurses
@sarah_janemad
24 May 2018 20:56
RT @WeNurses: Are you ready for QUESTION 5 ? Its all about changes ... #WeNurses https://t.co/A1oQbProo9
@4AdsthePoet
24 May 2018 20:56
#Wenurses https://twitter.com/4adsthepoet/status/999740969556807681
@WeNurses
24 May 2018 20:57
Good idea ? #Wenurses https://twitter.com/DeeDavies12/status/999740645836193794
@WeNurses
24 May 2018 20:57
RT @bjgw: Our board takes SI/RCAs very seriously all scoping and panels are chaired by an exec or senior manager @paula_shobbrook #WeNurses…
@CatherinePelley
24 May 2018 20:58
@WeNurses Focus on learning not timescales. Assurance of learning key rather than numbers and punitive/ performance #Wenurses
@modopickle
24 May 2018 20:58
RT @KatieAnnSiobhan: @MaryDunningTU @lilian_wittman @WeNurses #wenurses us family members we to reflect on in case of my brother Tim I ask…
@Lauren_e_Mosley
24 May 2018 20:58
@AlanJCard Like review a policy that wasn't read the first time ;-) #WeNurses
@WeNurses
24 May 2018 20:58
2 MINUTES LEFT Please do share your final thoughts #WeNurses
@Ruthiemccarroll
24 May 2018 20:58
RT @AgencyNurse: THIS #WeNurses https://twitter.com/sarah_janemad/status/999738255519121408
@bjgw
24 May 2018 20:58
RT @WeNurses: 2 MINUTES LEFT Please do share your final thoughts #WeNurses
@AlanJCard
24 May 2018 20:59
@Lauren_e_Mosley Yes! Or that the person knew perfectly well, but which is impossible to follow in real life! #WeNurses
@selenam738
24 May 2018 20:59
#wenurses https://twitter.com/ekhuftsos/status/952480332057628672
@PhyllisStein2
24 May 2018 20:59
RT @WeNurses: We've another #wenurses poll coming up... have you all answered this one first please :) https://twitter.com/WeNurses/status/999733481910538240
@AlanJCard
24 May 2018 20:59
RT @Lauren_e_Mosley: @AlanJCard Like review a policy that wasn't read the first time ;-) #WeNurses
@WeNurses
24 May 2018 21:00
Tonights #WeNurses is part of a wider consultation re the Serious Incident Framework ... & we encourage you to sha… https://t.co/c2bahZJQrK
@bjgw
24 May 2018 21:00
We all mistakes but Learning from those mistakes is crucial, crucial for staff and vital for pts #weNurses https://t.co/70tFlxgUdA
@modopickle
24 May 2018 21:01
#wenurses @QAHospitalNews we’ve adopted an organisational-wide standardised approach for displaying learning. It’s… https://t.co/C3QEsMjmMy
@mand1971
24 May 2018 21:01
RT @WeNurses: So lets get started with QUESTION 1 #WeNurses https://t.co/Pn1WbNdD42
@Trish_McKinney
24 May 2018 21:01
@Jo3_NHS @WeNurses This is so true #WeNurses but questions like... why was the policy not followed? Is it the righ… https://twitter.com/i/web/status/999742321469067266
@ptsafetyNHS
24 May 2018 21:02
RT @WeNurses: Tonights #WeNurses is part of a wider consultation re the Serious Incident Framework ... & we encourage you to share your vi…
@WeNurses
24 May 2018 21:02
Thank you to everyone who has taken part and shared their views tonight #WeNurses https://t.co/o9g1d79EWj
@Lauren_e_Mosley
24 May 2018 21:02
#wenurses fantastic suggestions and insight from #weNurses
@schoolnurse17
24 May 2018 21:03
Thank you - really interesting discussion #WeNurses
@AgencyNurse
24 May 2018 21:03
Thanks - great discussion tonight everyone #WeNurses
@24NRGgroup
24 May 2018 21:03
RT @SafetyDonna: #WeNurses Conducting fewer investigations is one way of freeing up resources to allow more in-depth investigations that i…
@nursemaiden
24 May 2018 21:03
How many organisations share learning across providers and commissioners? #Wenurses https://twitter.com/nitchola/status/999742382429097984
@modopickle
24 May 2018 21:03
#wenurses Well that hour went quick! Back to the homework..
@DrUmeshPrabhu
24 May 2018 21:03
@nursemaiden Spot on but look at the trends and and rest one must make judgement. DO NOT OVER BURDEN STAFF #WeNurses
@ashtullett
24 May 2018 21:03
@WeNurses #WeNurses
@PhyllisStein2
24 May 2018 21:04
RT @WeNurses: Tonights #WeNurses is part of a wider consultation re the Serious Incident Framework ... & we encourage you to share your vi…
@4AdsthePoet
24 May 2018 21:04
@PhyllisStein2 @WeNurses In worst cases, blaming bereaved families for the errors and retraumatising them (2) #Wenurses
@nursemaiden
24 May 2018 21:04
RT @WeNurses: Thank you to everyone who has taken part and shared their views tonight #WeNurses https://t.co/o9g1d79EWj
@MaryDunningTU
24 May 2018 21:04
@WeNurses #WeNurses more education and training on solution focused
@Lauren_e_Mosley
24 May 2018 21:04
thank you #wenurses and thank you @AgencyNurse for all your help
@WeNurses
24 May 2018 21:04
If you want to reflect on tonights #WeNurses for your CPD you can via MyWe HERE > http://www.wecommunities.org/MyWe #WeNurses https://t.co/sq2ro0rN3d
@SafetyDonna
24 May 2018 21:05
#wenurses ... thanks so much for your support! https://twitter.com/WeNurses/status/999742405741023232
@NRCUK
24 May 2018 21:07
@selenam738 @Jo3_NHS @WeNurses @EKHUFT @EKHUFTsos @Mwebb3Webb @EKHUFTicu sounds good :) #wenurses
@DrUmeshPrabhu
24 May 2018 21:07
@kateheydonorg @AgencyNurse Please do not insult garbage #WeNurses #CheekyUmesh
@PhyllisStein2
24 May 2018 21:07
@4AdsthePoet @WeNurses Yes I've never been invited to participate as a parent, just told, insulted etc + grateful for any apology #wenurses
@PhyllisStein2
24 May 2018 21:08
RT @4AdsthePoet: @PhyllisStein2 @WeNurses In worst cases, blaming bereaved families for the errors and retraumatising them (2) #Wenurses
@nursemaiden
24 May 2018 21:08
How can we spread this nationally #Wenurses https://t.co/ECATGQtWKk
@SafetyDonna
24 May 2018 21:08
#wenurses Fantastic! It sounds like a great idea. https://t.co/iPZeQIqZnP
@AlanJCard
24 May 2018 21:10
This should NEVER happen. But sometimes it still does. Don't be the person doing this. #WeNurses #ptsafety https://t.co/fHzFP4D4by
@gilmartt
24 May 2018 21:10
RT @WeNurses: Here's a useful diagram from the existing serious incidents framework .... seven key principles #WeNurses https://t.co/ByWQ…
@WeNurses
24 May 2018 21:10
So.. that was quick... Catchup on tonights #wenurses here http://wecommunities.org/tweet-chats/chat-details/4182 so really great sharing by you al… https://twitter.com/i/web/status/999744499642400768
@4AdsthePoet
24 May 2018 21:10
RT @AlanJCard: This should NEVER happen. But sometimes it still does. Don't be the person doing this. #WeNurses #ptsafety https://t.co/fHzF…
@sarah_janemad
24 May 2018 21:11
@WeNurses Thank you - excellent - you go easily do more on this ! #WeNurses
@sarah_janemad
24 May 2018 21:11
RT @WeNurses: If you want to reflect on tonights #WeNurses for your CPD you can via MyWe HERE > http://www.wecommunities.org/MyWe #WeNurses https://…
@AlanJCard
24 May 2018 21:12
RT @WeNurses: So.. that was quick... Catchup on tonights #wenurses here http://wecommunities.org/tweet-chats/chat-details/4182 so really great sharing by you all, thank y…
@gilmartt
24 May 2018 21:12
@WeNurses Hello I’m so late sorry (baby girl does not like sleeping) but having a retrospective ?? ??#wenurses
@Gemma_Louch
24 May 2018 21:13
Really insightful discussion - thank you #wenurses ?? https://twitter.com/wenurses/status/999744499642400768
@kwelsh1
24 May 2018 21:13
RT @AlanJCard: This should NEVER happen. But sometimes it still does. Don't be the person doing this. #WeNurses #ptsafety https://t.co/fHzF…
@WeNurses
24 May 2018 21:14
We shared two twitter polls during tonight's #WeNurses on "Learning from serious incidents" Would be great please i… https://twitter.com/i/web/status/999745417012236288
@Gemma_Louch
24 May 2018 21:14
RT @WeNurses: We shared two twitter polls during tonight's #WeNurses on "Learning from serious incidents" Would be great please if you coul…
@XMcVey
24 May 2018 21:16
RT @WeNurses: If you want to reflect on tonights #WeNurses for your CPD you can via MyWe HERE > http://www.wecommunities.org/MyWe #WeNurses https://…
@XMcVey
24 May 2018 21:17
RT @WeNurses: So.. that was quick... Catchup on tonights #wenurses here https://t.co/9aXXVQYFI7 so really great sharing by you all, thank y…
@PhyllisStein2
24 May 2018 21:18
RT @nursemaiden: How many organisations share learning across providers and commissioners? #Wenurses https://twitter.com/nitchola/status/999742382429097984
@gilmartt
24 May 2018 21:19
RT @Nitchola: @NRCUK @CatherinePelley @WeNurses There are definitely opportunities to reduce duplication across the system #WeNurses
@becksherrington
24 May 2018 21:19
RT @WeNurses: If you want to reflect on tonights #WeNurses for your CPD you can via MyWe HERE > http://www.wecommunities.org/MyWe #WeNurses https://…
@PhyllisStein2
24 May 2018 21:19
@nursemaiden @Nitchola @modopickle @WeNurses Sometimes HSE does http://www.heraldscotland.com/news/13156022.Plastic_bags_ban_in_mental_health_wards_after_suicides/ #wenurses
@MaryDunningTU
24 May 2018 21:19
@WeNurses #WeNurses education/training solution-focus Appreciative Inquiry process, engaging people. Working from p… https://twitter.com/i/web/status/999746794555887617
@nursemaiden
24 May 2018 21:21
RT @PhyllisStein2: @nursemaiden @Nitchola @modopickle @WeNurses Sometimes HSE does http://www.heraldscotland.com/news/13156022.Plastic_bags_ban_in_mental_health_wards_after_suicides/ #wenurses
@WeNurses
24 May 2018 21:22
Missed tonights #WeNurses on Serious Incidents ? Summary and transcript are here > http://www.wecommunities.org/tweet-chats/chat-details/4182 https://t.co/qkuQ3zmAie
@DrUmeshPrabhu
24 May 2018 21:23
RT @WeNurses: Missed tonights #WeNurses on Serious Incidents ? Summary and transcript are here > http://www.wecommunities.org/tweet-chats/chat-details/4182 https://t.co/qku…
@TyrrellTracy
24 May 2018 21:24
We need to ensure we capture learning and implement as soon as possible to avoid it happening again #WeNurses https://twitter.com/Lauren_e_Mosley/status/999739936692686849
@bill_russell3
24 May 2018 21:24
@WeNurses Just seen this. #Wenurses FYI I remember organising training for District Nurses back in 2002 on investig… https://twitter.com/i/web/status/999747933347237889
@TyrrellTracy
24 May 2018 21:25
Let's focus on those incidents we can learn from #WeNurses https://twitter.com/WeNurses/status/999736045334859776
@sarah_janemad
24 May 2018 21:27
RT @WeNurses: Missed tonights #WeNurses on Serious Incidents ? Summary and transcript are here > http://www.wecommunities.org/tweet-chats/chat-details/4182 https://t.co/qku…
@sheffnurse
24 May 2018 21:27
RT @WeNurses: Missed tonights #WeNurses on Serious Incidents ? Summary and transcript are here > http://www.wecommunities.org/tweet-chats/chat-details/4182 https://t.co/qku…
@WeStudentNurse
24 May 2018 21:28
RT @WeNurses: Missed tonights #WeNurses on Serious Incidents ? Summary and transcript are here > http://www.wecommunities.org/tweet-chats/chat-details/4182 https://t.co/qku…
@lilian_wittman
24 May 2018 21:31
RT @KatieAnnSiobhan: @lilian_wittman #wenurses failure in communication has been cropping up again and again throughout my brother's seriou…
@MRadford_DONi
24 May 2018 21:31
RT @WeNurses: Here's a useful diagram from the existing serious incidents framework .... seven key principles #WeNurses https://t.co/ByWQ…
@gilmartt
24 May 2018 21:33
RT @WeNurses: Tonights #WeNurses is part of a wider consultation re the Serious Incident Framework ... & we encourage you to share your vi…
@STPHCareers
24 May 2018 21:36
Want to work in #Covington, LA? View our latest opening: https://t.co/xhoDapYsj9 #HealthyNurse #WeNurses #Nursing #Job #Jobs #Hiring
@markhil75770073
24 May 2018 21:37
RT @WeNurses: Here's a useful diagram from the existing serious incidents framework .... seven key principles #WeNurses https://t.co/ByWQ…
@KenZeroHarm
24 May 2018 21:38
RT @SafetyDonna: #wenurses Some people worry that families will need us to investigate every single incident. But do we need to do that if…




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