Judy Walker

NHS England’s Patient Safety Team will be launching the new Patient Safety Incident Response Framework (PSIRF) in the Spring of 2022, and one of the tools it will recommend to enhance learning from events is After Action Review (AAR).  It is likely that each healthcare provider will define its own 'playing field' for AAR as the PSIRF is integrated in daily practice in the months and years ahead, yet this can extend far wider than many assume. In the 12 years since I was trained as an AAR Conductor, I have grown to appreciate its adaptability as well as the many benefits it delivers. The examples of real AARs described here are designed to illustrate some of the many applications. As you will see, these AARs have created opportunities for learning at three levels, all of which contribute to the delivery of safe and effective patient care: the individual, the team and the organisation.  Example 1. Organisational learning – AARs post-Covid One of the many hospitals that had to rapidly reconfigure services and respond to the first Covid-19 surge invited clinical and operational teams to participate in AARs on any topic of their choice. Over 140 staff, including porters, mortuary technicians, matrons, consultants, junior doctors and nurses at every grade participated in 10 AARs, focusing on learning from different aspects of the response, including the emergency and the elderly care units, the respiratory intensive care team and the redeployment and training activities. The themes emerging from the 10 AARs were synthesised into a report that senior leaders used to plan for the second surge. The findings of the report were also presented to 80 staff participating in the Leadership Forum. 100% of participants said it was a valuable activity and comments about what they found most valuable included: “Listening to my colleagues talking about their experiences and the challenges that they faced during the pandemic was most powerful” “[it] gave me an opportunity to speak up and voice my opinion to people I may not have otherwise.” Example 2. Learning from a clinical error A patient with a known penicillin allergy was prescribed and dispensed a penicillin-based antibiotic. The junior doctor and the nurse involved were invited to participate in an AAR with their respective senior colleagues. During the AAR, the doctor recounted the 2pm call on a busy Sunday from the consultant microbiologist telling him to take Mr Smith off IV antibiotics and prescribe him oral co-amoxiclav instead. The doctor noted this down and at 8pm eventually sat down with his 'lunch' and worked through his long list of notes and drew a line through the IV prescription and did what he had been instructed to do, prescribe co-amoxiclav. Then we heard from the nurse who described how at 7am she was rushing to complete the drug round before the day staff came on duty, whilst keeping an eye on Mr Jones who was trying to climb over the bed rails. She saw Mr Smith had a red alert allergy bracelet on and so asked if he was allergic to co-amoxiclav, to which he replied, “I don’t think so,“ and so she dispensed the antibiotic. Both the nurse and the doctor involved had been significantly distressed by their errors but during the AAR they learned for themselves how their actions took place in a wider context of distraction, not questioning hierarchy, and low blood sugar, and decided on actions to mitigate these in the future. The AAR also provided a place where the ward sister recognised that the criticism received by the night nurses for not completing drug rounds was impacting on patient safety. Example 3. Organisation response A small fire in the basement of an old ENT hospital building led to the safe evacuation of patients to another hospital and the relocation of the outpatients’ clinics for some weeks. Three AARs were held to learn from the response to the fire itself, the re-organisation of the services and the management of patient communications. Whilst no one was hurt in the fire, the AAR carried out on the response to the fire identified a significant risk, which led to the estates team undertaking an urgent review of fire alarms systems in all of the Trust’s buildings. Many of the fire alarms in place were battery operated and, although they worked as required, some of them ran out of power and gave a false indication that it was safe to re-enter the area. Other learning from the AARs consolidated understanding of what had worked well and ensured staff knew what their individual and collective actions had done to recover normal service. Example 4. Learning from complaints One specialist service used the AAR format to identify areas for service improvements on a clinical audit day. 40 staff worked in small groups, each reviewing a single complaint. This is what actually happened from the patient’s perspective, and then the groups explored what would normally be expected from the patient’s, family’s and hospital’s perspectives. This provided the material to explore what might have prevented the complaint, and where the areas for improvement should lie. Example 5. Rebuilding relationships Implementing significant upgrades in two counties’ GP practices’ IT capacity required the many moving parts to trust each other to complete their activities as planned. When a number of key personnel left both the CSU’s and CCG’s IT teams, the need to communicate and receive assurance about every step increased dramatically. After phase one of the IT project had been completed, an AAR was called by the CSU’s IT service provider because trust had broken down and the time spent proving assurance to the CCG customers was impacting on every aspect of the work. The re-telling of shared experience from different perspectives increased understanding of the bigger picture for all participants and they recognised the many similarities between them, rather than focusing on the differences. A fresh approach to communicating and providing a viable level of assurance was agreed and Phase Two was begun with some trust restored and a shared plan to increase IT staff recruitment in the region. 91% of participants said they learnt more than they expected during the AAR and 100% said what they learned would help them with their work in the future. Using AAR in your organisation As you can see, AAR is highly adaptable, incredibly useful and has proven efficacy, but using AAR successfully in your organisation, is unlikely to happen easily. Although AAR is essentially a simple four question model, its success relies on much more than the four questions. You will also need to consider the following : How will you ensure a consistent quality is achieved in every AAR so that participants can trust the process and valuable learning is obtained? Will anyone be able to lead an AAR or will they only be facilitated by trained AAR Conductors? How will you ensure there is clarity of when to conduct an AAR, and when to apply another approach? How will you communicate with the whole organisation about what to expect in an AAR and how to call one? How will you capture and share the learning form AARs whilst maintaining confidentiality? Who will have responsibility for managing the above? If you would like to talk to someone who is about as passionate about AAR as they come, and can help you answer these questions, please email me on [email protected]. Further reading Presentation on After Action Reviews from Judy Walker Patient Safety Managers creating a buzz around After Action Reviews How can After Action Review (AAR) improve patient safety?