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Learning from patient safety incidents including Human Factors

Event details

This one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace and is aligned with the new Patient Safety Syllabus and subsequent Patient Safety Incident Response Framework (PSIRF).

The new Patient Safety Strategy advises that organisations must adopt a new and broader approach to stimulate learning from patient safety incidents. This course is designed to assist healthcare professionals involved in this important work.

The main purpose is to provide learners with a full understanding of the various approaches that can now be used to conduct patient safety incident investigation (PSIIs). Traditionally, root cause analysis has been used as a blanket approach to diagnosing why patient safety have been compromised, but healthcare teams are henceforth being encouraged to adopt a wider range of methods that will both save time and facilitate enhanced learning. The focus is now on appropriate proportionality in response to incidents that occur in their organisation.

Key learning objectives:

  • Understand the new patient safety landscape
  • Understand the need for proportionality of investigation
  • Learn how to use a range of techniques for conducting PSIIs
  • Understand how to write an impactful improvement plan
  • Consider how your current approach to patient safety investigations compares to the agreed national standards
  • Understand typical pitfalls and traps associated with this wider work stream and tips for avoiding them.

The course is facilitated by Tracy Ruthven and Stephen Ashmore who have significant experience of undertaking patient safety reviews in healthcare. They were commissioned to write a national RCA guide by the Healthcare Quality Improvement Partnership. They have also authored articles on significant event analysis and clinical audit/quality improvement, all techniques seen as increasingly relevant to improving patient safety.


hub members receive a 20% discount. Email info@pslhub.org for the discount code.

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