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Found 27 results
  1. Content Article
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    As part of implementing the NHS Patient Safety Strategy, there are currently a number of new initiatives being rolled out across the NHS which are intended to achieve its vision of continuously improving patient safety. This includes the development of the Learn from patient safety events (LFPSE) service, for recording and analysing patient safety incidents, a new framework for involving patients in patient safety and the Patient Safety Incident Response Framework (PSIRF). PSIRF sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to p
  5. Content Article
    Tools and guides Patient safety incident investigation report template Introduction to SEIPS Four tools to help in the initial stages of a learning response Four guides to inform a response to a patient safety incident or cluster of incidents Four guides to support the exploration of everyday work Two tools to enable organisations to respond to broad patient safety issues Two tools to support information gathering and synthesis of information Developing safety actions
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    AAR is a deceptively simple process for learning from any every day or exceptional 'action', which takes the individual expectations and experiences of the same event to build a shared mental model of what happened and use this as the basis for learning and action planning. To be successful it is essential that AARs are led by a trained AAR 'Conductor' who uses a defined four-question process and a universal set of AAR 'ground rules' to create a safe learning environment. The other vital component, which is often missing, is the organisational context in which the AARs take place. This needs t
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    As an agency scrub nurse, I was booked to work out of London in a private clinic. This was to work two nights and two days in theatres. It was my very first agency shift. On the way to the theatres, escorted by a porter, I slipped on the stairs whilst holding on to the rails and fell, sustaining a right dislocated shoulder. I had it relocated in A&E in a local NHS hospital and was given entonox and morphine. I returned to London the next morning – the taxi fare of £220 was not covered by the clinic. I have now been unemployed for many weeks due to the injury. The Ag
  11. 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 an
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    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.
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    In conclusion, EMS colleagues and organisations may need support to embrace opportunities from case-based learning, but research is also needed to explore the wishes and opinions of bereaved families regarding the dissemination of any case-based lessons that need to be learned.
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    WHO's definition of an After Action Review and resources Guidance for After Action Review After Action Review infographic 3 minute video explaining the AAR practice as promoted by WHO, including the definition, the different methodologies and available resources. After Action Reviews and simulation exercises
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    Problems related to the care home and the company were known well before the Panorama expose in 2016. When the Panorama programme was aired it resulted in immediate closure of one home and all the homes which were operated by Morleigh being transferred to new operators. The Review includes reports of abuse against residents; residents being left to lie in wet urine-soaked bedsheets; concerns from relatives about their loved ones being neglected; reports of there being insufficient food for residents, no hot water and no heating; claims that dozens of residents were sharing one bathroom.
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    Over the past twelve years, I have helped dozens of organisations in the NHS, higher education and in corporate contexts start using AAR to improve the quality of learning after events. Yet despite the proven value of AAR to patient safety and team performance,[1] AAR is still not making the impact it can and should. This short article explains some of the barriers to implementation that I have encountered during this time so that you can mitigate for them in your own context. In 2009, I joined a team at University College London Hospitals (UCLH) that had adapted the AAR concept from the
  23. Content Article
    Last Friday I joined the Patient Safety Management Network where the topic of discussion was AARs – what was already known, what wasn’t, how people are implementing AARs, the benefits they’re seeing and what more is needed to help people share their experiences and useful ‘how to’ resources. Here I’ll briefly summarise this valuable discussion and the insights shared by members of the Network, which included both Patient Safety Managers and Assistant Directors of Patient Safety and Quality, with a wide range of professional backgrounds and knowledge in the topic. This is ahead of Judy Wa
  24. Content Article
  25. 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 th
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