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Found 45 results
  1. Event
    This is for those in NHS Trusts in England only. This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course is includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. Learning objectives: Define what After Action Review is. Understand the principles of After Action Review. Know the attributes needed to be an After Action Review facilitator. Understand how to conduct an After Action Review. Register
  2. Event
    This is for those in NHS Trusts in England only. This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course is includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. Learning objectives: Define what After Action Review is. Understand the principles of After Action Review. Know the attributes needed to be an After Action Review facilitator. Understand how to conduct an After Action Review. Register
  3. Event
    This is for those in NHS Trusts in England only. This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course is includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. Learning objectives: Define what After Action Review is. Understand the principles of After Action Review. Know the attributes needed to be an After Action Review facilitator. Understand how to conduct an After Action Review. Register
  4. Event
    This is for those in NHS Trusts in England only. This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course is includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. Learning objectives: Define what After Action Review is. Understand the principles of After Action Review. Know the attributes needed to be an After Action Review facilitator. Understand how to conduct an After Action Review. Register
  5. Content Article
    This is a video presentation from the Royal College of Surgeons in Ireland, looking at facilitation skills for after action reviews (AAR) and the wider process.
  6. Content Article
    Innovation in the education and training of healthcare staff is required to support complementary approaches to learning from patient safety and everyday events in healthcare. Debriefing is a commonly used learning tool in healthcare education but not in clinical practice, but little is known about how to implement debriefing as an approach to safety learning across a health system. After action review (AAR) is a debriefing approach designed to help groups come to a shared mental model about what happened, why it happened and to identify learning and improvement. This paper describes a digital-based implementation strategy adapted to the Irish healthcare system to promote AAR uptake. The digital strategy aims to assist implementation of national level incident management policies and was collaboratively developed by the RCSI University of Medicine and Health Sciences and the National Quality and Patient Safety Directorate of the Health Service Executive. During the Covid-19 pandemic, a well-established in-person AAR training programme was disrupted and this led to the development of a series of open access videos on AAR facilitation skills (which can be accessed via the link to the paper). These provide: an introduction to the AAR facilitation process a simulation of a facilitated formal AAR techniques for handling challenging situations that may arise in an AAR reflection on the benefits of the AAR process. These have the potential to be used widely to support learning from patient safety and everyday events including excellent care.
  7. Content Article
    Work to prepare for transition to working within the Patient Safety Incident Response Framework (PSIRF) in the Autumn of 2023 is well underway by healthcare providers across England. Written for all those involved in implementing PSIRF, this article describes some of the reasons behind the challenges being faced and suggests three principles to help navigate through this complex process and offers practical ideas to help.
  8. Content Article
    This blog captures a recent discussion at a Patient Safety Management Network (PSMN) meeting, where members of the network raised a number of important questions and issues relating to the Patient Safety Incident Response Framework (PSIRF). PSIRF is currently being rolled out across all NHS trusts in England and takes a new approach to investigating patient safety incidents.
  9. Content Article
    The Patient Safety Incident Response Framework (PSIRF) supporting guidance “Engaging and involving patients, families and staff following a patient safety incident” presents the moral and logical arguments for engaging with those affected by a patient safety incident and involving them in a learning response. This article builds on the guidance given to describe how After Action Review (AAR) can be used to ensure patients and their families and carers can and do make a significant and meaningful contribution to the learning process.
  10. Content Article
    Judy Walker talks about improving team performance through the After Action Review approach and the importance of AAR Conductor training.
  11. Content Article
    In this blog, Judy Walker, an After Action Review (AAR) expert, looks at how effective learning from disasters and incidents can restore hope and trust, offering long-term improvements to systems that have failed. She talks about how public inquiries, although they can seem frustratingly slow, benefit society when the relevant authorities ensure that learning is understood and implemented. She compares this to the impact of AARs, highlighting that people’s trust in the process is linked to their perception of the changes that happen as a result of the AAR. She outlines three steps that NHS providers should take to ensure the AAR process is effective in restoring hope: Highlight to all staff on a regular basis, the benefits that are being delivered due to AARs Ensure patients and family members are provided with specific information about how AARs prevent future harms Support the people who lead AARs to do so skilfully, so that quality is assured and staff can trust in the safety and value of the process.
  12. Content Article
    This paper, published in Applied Ergonomics, looks at how those in healthcare might select which technique to use to predict error. The author concludes: "there is a lack of practical experiences described in the literature to conclusively define a technique for selection and a need for a dedicated research in this area to make it accessible for healthcare and other novice users".
  13. Content Article
    In this blog, Judy Walker, Senior Business Consultant at iTS Leadership, describes an After Action Review (AAR) that took place at a large London hospital following the first wave of Covid-19. As part of the AAR, Emergency Department porter Aaron described his experience of the first Covid 19 surge—wheeling large numbers of patients who had died through an empty hospital. Judy describes the value of staff listening to different perspectives as a way to reflect on their own experiences and understand the impact events have on different individuals. She highlights the importance of listening to the process of learning for individuals and teams.
  14. 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. 
  15. 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.
  16. 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.
  17. 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.
  18. 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.
  19. 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.
  20. 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.
  21. 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.
  22. 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.
  23. 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.”
  24. Event
    This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. You’ll also be directed to specific activities designed to extend and consolidate your knowledge. Register
  25. Event
    This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. You’ll also be directed to specific activities designed to extend and consolidate your knowledge. Register
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