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Found 46 results
  1. Content Article
    Reducing stress is an organisational imperative since workplace pressures continue to be one of the main causes of short and long-term absence. According to research undertaken by CIPD based on responses from 804 organisations, 79% of respondents report some stress-related absence in their organisation over the last year. Healthcare settings have an even higher rate of absence due to stress, yet there is reason to be optimistic that this could start to change when a new policy from NHS England is implemented, which recommends the use of After Action Review (AAR). In this blog, Judy Walker explains how AARs can play a key role in reducing stress for those who have been involved in clinical incidents.  
  2. Content Article
    The debate about which is better for learning, listening or talking, highlights one of the reasons why the After Action Review (AAR) can be such a powerful agent of change, as Judy Walker explains in her LinkedIn article.
  3. Content Article
    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. 
  4. Content Article
    Judy Walker, iTS Leadership, presented at the recent Patient Safety Management Network drop-in session on After Action Reviews. View the presentation below.
  5. Content Article
    Julie Avery and Brian Edwards, Chartered Institute of Ergonomics and Human Factors, presented at the recent Human Error Forum. They share their presentation slides on human performance and organisational learning and how to integrate human performance into existing systems.
  6. Content Article
    In this blog, Patient Safety Learning’s Chief Executive, Helen Hughes, highlights a recent discussion at a meeting of the Patient Safety Management Network about how After Action Reviews (AARs) can help promote learning and patient safety improvement.
  7. Content Article
    The broad aim of the webinar, run by CloserStill Media, is to promote After Action Review (AAR) as a valuable tool to promote learning and patient safety improvement and to: show how AAR can support, empower and enable teams to identify learning and good practice share knowledge on how to apply AAR for impact excite potential new users to adopt this approach. Judy Walker, a leading expert in AAR and its adoption for impact in healthcare, will set the scene explaining "What is AAR, why is it so valuable and what helps successfully embed it in organisations.”
  8. Content Article
    External clinical harm reviews aim to give assurance to patients, patient groups, commissioners and the public as to whether any patients have been harmed as a result of an incident, as well as to avoid future harm to patients. This handbook by Dr Henrietta Hughes, NHS Medical Director for London North, Central and East, outlines an approach to conducting clinical external harm reviews. It identifies the factors which make external clinical harm panels successful and provides example agendas and terms of reference for the process.
  9. Event
    The broad aim of the webinar is to promote After Action Review (AAR) as a valuable tool to promote learning and patient safety improvement. It will: • Show how AAR can support, empower and enable teams to identify learning and good practice • Share knowledge on how to apply AAR for impact • Excite potential new users to adopt this approach Judy Walker, a leading expert in AAR and its adoption for impact in healthcare, will set the scene explaining ‘What is AAR, why is it so valuable and what helps successfully embed it in organisations.” To demonstrate that AAR is a practical and valuable ‘how to tool,’ we want to share case study evidence from healthcare clinicians and leaders. We’re looking to showcase the experience of 3 or 4 organisations, sharing why they have adopted AAR and the benefits planned and impact. Register
  10. Content Article
    How does putting limitations around something boost innovation and learning? It may seem counterintuitive, but there is plenty of evidence to suggest that humans respond well to having some constraints imposed upon them. Judy Walker explains further in this blog.
  11. Content Article
    After Action Review (AAR) is a tried and tested, evidence-based approach that increases learning after events but, despite the clear benefits to patient safety and team resilience, its use in the NHS is still more limited than it should be. Judy Walker explains three of the barriers seen in clinical settings.
  12. Content Article
    I would like to share with you my experience of an injury I sustained when working as an agency nurse doing bank shifts in a private hospital and highlight to colleagues the importance of knowing your entitlements when working for an Agency. Please make sure you are adequately covered for injury.
  13. Content Article
    An example of how After Action Reviews are used by the US Army. An After Action Review (AAR) is a professional discussion of a training event that enables Soldiers/units to discover for themselves what happened and develop a strategy for improving performance. Facilitators provide an overview of the event plan (what was supposed to happen) and facilitate a discussion of what actually happened during execution.
  14. Content Article
    Debriefs (or After Action Reviews) are increasingly used in training and work environments as a means of learning from experience. Tannenbaum and Cerasoli assessed the efficacy of debriefs with a quantitative review and found organisations can improve individual and team performance by approximately 20% to 25% by using properly conducted debriefs.
  15. Content Article
    Organisational learning requires that teams continuously assess their performance to identify and learn from successes and failures. The After Action Review (AAR) is a simple but powerful tool to help you do this. Conducting an AAR at the end of a project, program or event can help you and your team learn from your efforts. Furthermore, sharing the results from your AAR can help future teams learn your successful strategies and avoid pitfalls you have worked to overcome.
  16. Content Article
    Elderly people in care homes in Cornwall were abused and neglected while failings led to reports of concerns not being investigated, a new Safeguarding Adults Review has found. The Morleigh Group, which operated seven homes in Cornwall and has since shut down, was exposed in a BBC Panorama investigation in 2016. A new Safeguarding Adults Review which was commissioned as a result of the TV show has been published making a number of recommendations to all agencies which were involved in the case. The review was completed in April 2019 but has only just been made public - Rob Rotchell, Cornwall Council Cabinet member for adult social care said that this was due to the number of agencies being involved.
  17. Content Article
    First used by the US army on combat missions, the after action review is a structured approach for reflecting on the work of a group and identifying strengths, weaknesses and areas for improvement. This NHS Improvement document explains what an after action review and when and how to use it.
  18. Content Article
    In January 2016, a high-profile local inquest examined the death of Jasmine Lapsley, a six year old child who sadly died after choking on a grape. One of Bangors post-ACCS Clinical Fellows (not involved with the case) attended the inquest with the intention of sharing any learning points at a CPD Day for Emergency Medical Service (EMS) colleagues we were due to hold six weeks later.  Upon releasing the CPD Day programme, organisers realised some EMS colleagues were profoundly uncomfortable about this talk, stating concerns such as 'talking publicly about lessons learned might upset the bereaved family'. They decided to ask all delegates at the CPD day what they thought of the inclusion of this item on the conference programme before and after the talk. This poster shows the results. 
  19. Community Post
    Dear hub members We've a request to help from New South Wales. They and their RLDatix colleagues request: The public healthcare system in New South Wales (NSW), Australia is changing how we investigate health care incidents. We are aiming to add to our armoury of investigation methods for serious clinical incidents and would love to hear your suggestions. Like many health care settings worldwide, in NSW we have solely used Root Cause Analysis (RCA) for over 15 years. We are looking for alternate investigation methods to complement RCA. So we are putting the call out … Are there other serious incident investigation methods (other than RCAs) you would recommend? What’s been your experience with introducing and/or using these methods? Do you have learnings, data or resources that you could share? Do you have policy or procedure documents about specific methods? Any journal articles – health care or otherwise – that are must-reads? We've many resources on investigations on the hub and recent thinking in the UK and internationally that might be of value including: UK Parliamentary report - Investigating clinical incidents in the NHS and from that the creation of A Healthcare Safety Investigation Branch applying a wide range of methodologies in national learning investigations informed by ergonomics and human factors UK's NHS Improvement recent engagement on a new Serious Incident Framework (due to piloted in early 2020) Dr Helen Higham work with the AHSN team in Oxford to improve the quality of incident investigations Patient engagement in investigations Lessons to be learned from Inquiries into unsafe care and reflections on the quality of investigations Insights by leading investigators and resources written specifically for us by inclusion our Expert Topic Lead @MartinL Do check these out in this section of the hub https://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/ Please add to this knowledge and give us your reflections. We'd be happy to start up specific discussions on topics of interest. Thank you all, Helen
  20. Content Article
    The WHO guidance for after action review (AAR) presents the methodology for planning and implementing a successful AAR to review actions taken in response to public health event, but also as a routine management tool for continuous learning and improvements. Four formats of AARs are described including the debrief, working group, key informant interview and mixed method AARs, and the accompanying toolkits containing materials to support the designing, preparing, conducting, and following up on each AAR format. Whilst the AAR methodology described in this document can be used for any response, a specific guidance to conduct an AAR following the response to emergencies that were not caused by biological hazards such as natural disasters is also provided to help the health sector to review its specific contribution to the multisectoral response and coordination.
  21. Content Article
    The NHS Long Term Plan highlighted several safety issues that need to be addressed: the fear of blame and retribution which curtails reporting and learning, lack of staff understanding of patient safety matters and workforce issues. This short article summarises what I have learnt about how After Action Review (AAR) can directly address the first two of these and indirectly impact on the third. 
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