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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 patient safety incidents. It promotes systems-based approaches for learning from incidents, rather than methods that assume simple, linear identification of a single cause. A key aim of the Patient Safety Management Network (PSMN) is to provide those working in patient safety with a shared space to discuss new policies that impact their work, and to share knowledge and resources with their peers. In this session, the Network considered how the systems-based approaches to incidents recommended by PSIRF can be implemented in practice. They focused on an example that used two of these tools in relation to a specific patient safety incident—an After Action Review (AAR) and an observational analysis, Patient safety incident The example discussed in this meeting was shared by a Patient Safety Manager who had applied two PSIRF tools to a specific patient safety incident that took place on a surgical ward, where an elderly, partially-sighted patient was due to be discharged. The original intention was to consider the implications of applying these tools to two separate incidents, but due to the level of discussion around the first incident there was not time to do this. However, Network members agreed on the value of having a future session focused on another example. In this case, an Internationally Educated-Nurse (IEN) came to issue a patient with medication on discharge. On the ward they took out medication from a POD locker (‘Patients Own Drugs’ - a bedside cabinet designed to offer safe and secure medication storage) and, when distracted by another task in a busy ward, put this on a side along with medication issued for the patient by a pharmacy. Subsequently, the patient took away both sets of medication, however it transpired that the medication in the POD locker belonged to another patient. The patient took the incorrect medication following discharge and was subsequently readmitted to hospital with an irregular heartbeat. To analyse this incident, the Patient Safety Manager decided to apply the Human Factors and ergonomics tools being promoted through PSIRF rather than undertake a Root Cause Analysis recommended by the Serious Incident Framework. After Action Review In response to this incident, first an AAR was undertaken. This is a structured review based on four questions aimed at understanding what happened, why it happened and how it can be done better by those responsible and involved in the incident. This review was undertaken by the Patient Safety Manager and a colleague in the Patient Safety team, and involved all staff involved in this incident including the Ward Manager and the IEN. In this case, there were specific reasons why it did not involve the patient, although AARs often can. The review concluded that: What was expected to happen? The patient should have been delivered the correct medication by the IEN, which should have been checked by another staff member as the IEN was still waiting their PIN (registration code from the Nursing and Midwifery Council). What actually occurred? The patient was sent home with the medication belonging to another patient which when taken, resulted in a hospital re-admission. Why was there a difference between what was expected and what actually happened? The IEN was not aware they required supervision discharging patients with medication (the ward coordinator was not aware they did not have their PIN yet), the POD locker was not emptied after the last patient and the ward was short staffed. What was the learning? Staff coordinating the ward need to be aware of IEN capabilities, IENs need to be aware of restrictions prior to receiving their PIN, POD lockers require checking on discharge of patients. Observational analysis The Patient Safety Manager felt that the AAR alone hadn’t necessarily provided the team with enough insights into the issues involved in the incident and decided to apply another recommended PSIRF tool, an observational analysis. The intention of this was to understand how the ward worked in relation to patients receiving medication from POD lockers on discharge, seeing ‘work-as-done’ as opposed to ‘work-as-imagined’ by staff in this area. This observational analysis was done using a locally adapted version of the tools recommended by PSIRF. Findings of the observation included: Environment – The ward was busy, noisy, and hot, with lots of activity taking place in a small space. The POD lockers themselves were not easily visible as white boxes on white wall. Person – There was limited communication between porters and nurses and limited dialogue/handover/briefing before a patient transfer. Organisation of work – Workload was extremely high. The POD locker was not checked routinely, and it was unclear whose responsibility it was to check medications in the lockers. Tasks – The task of checking a POD locker once a patient has moved is a simple one, but needs to be performed by a trained nurse and faces the competing priorities of patient care and patient flow. Technology and tools – POD lockers are not all in the same places, not all nurses have keys to them and there are no visual cues to check the lockers when a patient is moved or when there are drugs in them. Evaluating the findings of this observational analysis, a key issue not picked up as clearly by the AAR in this case concerned the POD lockers—namely the lack of operating procedures and routine around these, limited staff having access to them and there being no clear responsibility for checking and clearing them. Following completion of the AAR and observational analysis, both documents were uploaded to the Trust’s incident reporting system and an outcome letter was shared with the patient’s family, detailing what issues had been found and what action would be taken to address these. The family were appreciative of the information and were reassured that learning was being applied that would prevent future harm to patients. The action to address the issues identified in the observation included referral to the Trust-wide Medicines Management Committee for review of the need for improvements in the management of medication and POD lockers. Network discussion In the subsequent discussion of these approaches to analysing and learning from this patient safety incident, there were a range of reflections from Network members: In relation to the specific patient safety incident: It was noted that in this case, involving the IEN in the AAR was positive as it provided immediate reassurance to the staff member that the aim of this review to learn rather than blame, as the IEN had concerns about the professional consequences of this error and the potential impact on their employment status. There was a discussion of whether it would make sense to do a short-term fix with regards to the POD lockers, such as painting them a distinct colour, and whether this would have a significant positive impact, or potentially unintended consequences if done in isolation of other quality improvement activities. An interesting outcome in this case is that the AAR review seemed much more centred on the individual involved in the incident, while the observational analysis drew our wider environment factors. In relation to the application of PSIRF tools more broadly: There were questions about how information from AARs, observations and other new PSIRF tools would subsequently feed into organisational plans. It was posited that these could be reviewed at regular intervals (for example, every three months) by the patient safety team, and their insights used to feed into an organisation-wide quality improvement project, or a thematic review. PSIRF highlights the new approaches and tools to be adopted, but organisations need to consider how they respond to the outcome of new tools and how information is reported and acted on with quality improvement projects and organisational oversight. There was a question about whether the staff conducting the AAR and observational analysis got the right support. A question was posed as to whether there could be an opportunity for a constructive friend challenge by a Human Factors expert or discussion about how this was approached afterwards? There was an acknowledgement that sometimes it can be difficult to define what observations fit into which SEIPs categories—for example, something in the ‘Environment’ that may also fit under the ‘Technology and tools’ heading. Also, a question was asked as to whether this matters as long as the learning is recorded. It was noted that training for PSIRF tools is covered in Healthcare Safety Investigation Branch training, but that it would be helpful if there were also simple practical guides to help staff when undertaking these reviews. In relation to the observational analysis: There was also discussion about how to approach observations of this type. Many highlighted the issue that when staff know they are being observed, they potentially act differently. The question was raised as to how close you get to seeing an accurate reflection of ‘work-as-done’—is the presence of someone observing having a significant impact on how activities are being approached? Other points raised included: An observational analysis of this type can be easily done in a hospital, but how effective or simple would it be to perform it in a community setting, for instance if the issue occurred involving a nurse in a patient’s home? Would it potentially be better to do observations while also doing a shift on a ward, as opposed to joining simply to do an observation? Or would this add in unexpected bias into the process? Is there more to be done for staff to understand how to ‘observe well’? With training or guidance from Human Factors/ergonomics experts? If the aim is to create an open, learning culture, it is important that staff are aware they are being observed so that they do not feel they are being spied on. It is important to clearly communicate the aim of an observational analysis to staff, highlighting that it is fundamentally to understand their work and improve safety. Concluding comments At the session there were a number of positive reflections on the use of new PSIRF tools and their potential to improve learning from patient safety incidents. The discussions also underlined the importance of ensuring that staff have the appropriate support and training to help embed the use of the tools and develop how the outcomes of each tool inform improvement and organisational oversight. How to get involved in the PSMN Are you a patient safety manager interested in joining the Patient Safety Management Network? You can join by signing up to the hub today When putting in your details, please tick ‘Patient Safety Management Network’ in the ‘Join a private group’ section. If you are already a member of the hub, please email claire@patientsafetylearning.org Related Reading Applying the After Action Review for the PSIRF – some real life examples (10 March 2022) Observational tools, Human Factors and patient safety: a recent discussion at the Patient Safety Management Network (9 March 2022) Patient Safety Management Network – the time is now (25 October 2021)

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 Walker, a subject matter expert in the AAR approach, joining the Patient Safety Management Network meeting on Friday 19 November to share her expertise and participate in discussion with the group. AARs and patient safety Current NHS guidance on the new Patient Safety Incident Response Framework states: “An organisation’s Patient Safety Incident Response Plan should set out its approach to the different types of patient safety incident identified from the local situational analysis, acknowledging that this will include ‘do not investigate’ or ‘no response required’. An organisation must have systems to ensure the approach and tools it uses in its response to a patient safety incident achieve useful learning/insight and outline the circumstances where they are indicated – in its PSIRP.”[1] In listing techniques for responding to patient safety incidents, the guidance includes AAR as one approach to this, describing this as: “ A structured, facilitated discussion on an incident or event to identify a group’s strengths, weaknesses and areas for improvement by understanding the expectations and perspectives of all those involved and capturing learning to share more widely.”[1] This slightly differs from the World Health Organization (WHO), who define this as: “...a qualitative, structured review of the actions taken in response to an event, as a means of identifying and documenting best practices, gaps and lessons. The review seeks to identify immediate and longer-term corrective actions for future responses. An AAR can focus on a single, specific function or on a broad set of functions, covering one or more sectors involved in the response.”[2] What do Patient Safety Managers know about AARs? Knowledge and experience of AARs varied widely among the Patient Safety Managers at the meeting. Some are leading their organisation's approach to implementing AARs and are seeing strong impact in improving patient safety, with clinicians welcoming and embracing this learning and collaborative review approach. Others spoke about how they are developing their ideas and will be adopting AAR at an organisational and ward/service delivery level, while for some this was something that was coming further down the line and they wanted to find out more. The group shared their experiences, templates, successes and uncertainties. This is exactly what the Patient Safety Management Network is about: collaboration, shared learning, peer support and responding to requests for help. There was a real ‘buzz’ in the discussion, amazing for a online Teams call! So, in summary here are some of the issues discussed as well as suggestions, ideas and questions: Are people doing AARs? One Patient Safety Manager said that her organisation expects clinical staff to be doing AARs but without a structured implementation plan and training. Its therefore not surprising that staff are left puzzled at what to do in practice. The risk is that without guidance, AARs are being completed as if they were Serious Investigation forms, providing more of a description of events rather than informing learning or action. Another Network member said that they have been using AARs in reviews of delayed cancer care and that this had been working really well. They noted that AARs facilitated by the Patient Safety Managers and really embraced by clinical teams helped to capture good practice too. AARs can help to support learning from the ‘shop floor’, empowering frontline clinicians to support improvement locally as well as wider organisational learning. People are often hung up on timelines when they undertake investigations and are not looking at the ‘bigger picture;’ AARs can really help. There were concerns shared from a Network member from a major Acute Trust about them not yet implementing AARs and not having plans in place to do so. There were also some concerns about the practicalities of dong AARs at scale, for example doing AARs for each patient fall in a month. What support is needed to help use AARs to improve patient safety? Coaching skills, training and support to make sure we get the most out of AARs. Models of good practice to ensure that they are not introducing cognitive bias and the value that independent convenors can bring to this, such as an independent medic from a different clinical area providing professional challenge. Information on convenor roles (the ‘facilitator’ in undertaking AARs). Guidance on how to engage with families and manage their expectations: - before an AAR (to explain what's going to happen) - involvement of patients/families in an AAR - with the outcome and in the context of Duty of Candour, will an AAR be enough? What benefits are being seen from the use of AARs? Quicker learning and focus on action. Examples of learning from good practice. A move away from long reports that focus on descriptive detail to shorter reports that focus on learning and action. Multi-disciplinary learning and open engagement and discussion across teams. Moving away from a ‘policing model’ of investigations; focus on human working in complex environments with processes and systems, and not so hung up on timelines. Self-discovered learning by engaging in AARs; change that is owned by staff; also getting ward engagement in problem-based learning. A way to focus on Trust-wide implementation; the whole system being designed to keep patients safe. Questions of policy and governance How best to engage patients and families in AARs? To provide support, to source their views, to manage expectations (‘it’s not an investigation’). What are Clinical Commissioning Groups (CCGs) expecting from the new Patient Safety Incident Response Framework and AAR? Do CCGs want to see the detail of every investigation, AAR or thematic review and/or ‘the bigger picture’ issues emerging from these? Discussion suggested that CCGs/Integrated Care Systems (ICS) would want to see Trust-wide action plans not just those focused on individual units/Directorates. Should AARs be done on every incident or specific selection of events? For example one hospital is planning to do an AAR on every fall, whether this results in serious harm or not, while another has 200 falls a month and doesn’t have the capacity to do an AAR on every incident. What will organisation leaders expect to see from AARs? How will they be assured of the quality of the review when reports are shorter? This might be particularly of concern for AARs into deaths by suicide, where panels are used to receiving very detailed reports. Context of incidents is hugely important. Discussion was that AARs should focus on the incident but with the analysis highlighting context, causal factors and what action is needed. The need for ‘protected’ time to complete AARs. Value of appreciative inquiry and learning from what works well. Otherwise, it’s as if we’re “learning about sharks just from shark attacks”. Patient Safety Managers will have to ‘let go’ and support AARs wherever incidents take place, rather than controlling the process. Very different solutions for ward-based activity compared to theatres. The measure of success will be when there are fewer falls, for instance. How will the learning from AARs be shared within and between organisations? What is your experience of AARs? Share your resources with us During the course of this discussion many members of the Patient Safety Management Network volunteered to share their templates, presentations, training resources and guides related to AARs. These will shortly be added to the Network’s community on the hub. Do you have AAR resources and good practice to share? Included at the end of this blog is some related reading on this topic and we’d welcome further additions to the hub. If you’re a Patient Safety Manager interested in joining the Patient Safety Manager Network, you can do so by signing up to the hub today. If you are already a member of the hub, please email claire@patientsafetylearning.org. References NHS England and NHS Improvement. Patient Safety Incindent Response Framework 2020: An introductory framework for implementation by nationally appointed early adopters. March 2020. WHO. After Action Review. Last Accessed 9 November 2021. Related reading Salem-Schatz S, Ordin D, Mittman B. Guide to the After Action Review. Center for Evidence-Based Management, December 2010. CloserStill Media. Learn faster and better together: The power of After Acton Review (webinar recording). 4 June 2021. Judy Walker. How can After Action Review (AAR) improve patient safety? the hub, 23 August 2019. Judy Walker. Why isn’t After Action Review used more widely in the NHS. the hub, 1 February 2021. NHS England and NHS Improvement. After Action Review. August 2021. United States Army Combined Arms Center. The Leader’s Guide to After-Action Reviews (AAR). December 2013. WHO. After Action Review (AAR) resources. 11 November 2019.

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 judy.walker@its-leadership.co.uk. 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?

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