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Judy Walker Associates: AAR training course
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Judy Walker Associates are hosting a training day in London on 2 October for individuals, rather than groups to attend. We’ve been receiving requests from people in primary care, independent providers and previous clients for individuals to access our professional development for AAR Conductors, so are happy to accommodate. Participants will get live AAR practice and feedback, learn about the Five Switches of advanced facilitation and understand how to involve patients and families successfully in AARs. Please get in touch and we can send you a flyer [email protected]- Posted
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Judy Walker believes that the 'expectations' question in After Action Reviews is the one that has the most potential to bring about change and improve a culture. *This article was first published in The After Action Review Newsletter June 2025 written by Judy Walker Associates Ltd. Each of the four AAR questions has its strength, but I believe that it is the expectations question that is the one that has the most potential to bring about change and improve a culture. This is because it is the one we are least likely to ask and yet it is the one which uncovers the powerful assumptions that were guiding the behaviour and beliefs of those involved in any action. Expectations are included in what Shorrock describes as “work as imagined” and “work as prescribed” but they go even deeper. Our cultural norms, professional roles, experiences at work as well as policy and practice shape what we expect to have happen, but much of this happens outside of our conscious awareness. Being asked it in an AAR enables us to hear our own and others’ expectations, usually for the first time. This is where the first learning takes place in an AAR. You can literally see the light bulbs switching on as the synapse connections are made. What is particularly interesting is that when teams use AAR routinely, the expectations concept starts to infiltrate how they think, and it becomes a question that is asked elsewhere to good effect. For example, “I wonder what the patient is expecting will happen today?” or “What are you expecting from your first week on the ward?” to bring the underlying assumptions to light. Asking the question creates double loop learning about how our expectations may all be different unless we stop to explore them. I learned a huge amount from the many people I have taught to use AAR over the past 15 years. In one team that used AAR regularly to learn from clinical events, I saw an amazing application of the expectations question to a recruitment process. To ensure that they received a high number of recruits to the Registrar posts at a Level 3 Neonatal Intensive Unit, the Neonatal Consultant was very efficient and got an advert out early. This meant they were overwhelmed with top class applicants, and in preparing for the interviews, the Consultant realised that many would meet the Essential Criteria specified by the organisation’s’ interview process, so she developed some key questions for the Desirable criteria, one of which was “What do you expect it will be like working in a city centre Tertiary Neonatal Unit?”. This question got a wide range of responses, such as “I expect there will be good Consultant support, for it to be stressful at times, with some weekend shifts, perhaps one in 6 weekends.” Others answered, “I expect to be able to call Consultants if needed, for it to be very emotionally demanding work and to work one in four weekends”. The Registrar posts were awarded to those who met all the Essential Criteria and whose expectations most closely matched the harder reality, and at the end of their year on the ward, a surprising thing happened. The GMC National Training Survey scores for the unit were the highest in the country. The appointed Registrars who had expected it to be tough work, had realistic expectations about their workload and the emotional demands entailed. In other words, there was no gap between their expectations and the reality, and possibly the work experience was better than they expected, so their satisfaction with their training position was positive. Have you found a useful application of the Expectations Question? We would love to hear about it and share it with others in the AAR community. Please get in touch [email protected] -
Event
An After Action Review is a facilitated discussion following an event to understand what happened and why, and how it could be improved from the perspective of those who were involved. There is an emphasise on facilitation of active awareness and self learning to lead to lasting change and improvement. AARs are included as an investigation and learning tool under the Patient Safety Incident Response Framework (PSIRF). The morning will be a hands on interactive masterclass which will develop your skills in conducting an AAR using simulated case study AAR examples and facilitated discussion. The afternoon will focus on case study sessions from experts who are using AAR in practice. Topics will include AAR under the Patient Safety Incident Response Framework (PSIRF), walkthrough case studies of AAR in action, the role of human factors in AAR and delivering change. There will be an extended focus on informing and involving patients in AARs in line with national guidance “Many national reports clearly articulate the importance of engaging with patients, families, and staff appropriately after a patient safety incident and involving them in any subsequent investigation.” NHS England. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/after-action-reviews or email [email protected]. Follow the conference on X @HCUK_Clare #AfterActionReviews hub members receive a 20% discount. Email [email protected] for discount code. -
Content Article
The way in which healthcare organisations are expected to respond after patient safety events in England changed significantly in August 2022 when the new Patient Safety Incident Response Framework (PSIRF) was introduced. What has actually happened is that the new processes built around the use of the Learning Response Tools in general and for After Action Review (AAR) in particular, are very varied. In this article, Judy Walker looks at the the variation in executing AARs and why this risks jeopardising the very essence of the AAR. *This article was first published in The After Action Review Newsletter May 2025 written by Judy Walker Associates Ltd. The way in which healthcare organisations are expected to respond after patient safety events in England changed significantly in August 2022 when the new Patient Safety Incident Response Framework (PSIRF) was introduced. What has actually happened is that the new processes built around the use of the Learning Response Tools in general and for After Action Review in particular, are very varied This is not surprising and is not concerning, as the PSIRF is purposefully designed to empower healthcare providers to implement in the framework in the way that suits their context best. However, I am concerned that the variation is also being manifested in the approach taken within the execution of the AAR itself, which risks jeopardising the very essence of the AAR. One of the risks is to the quality of the engagement and accountability with those who are attending the AARs. It was an excellent article published by Psychological Safety, on the Spectra of Participation which explores these concepts that gave me the idea for a framework for describing what I have observed that is a concern. Participation doesn’t guarantee engagement Looking at the IAP2 and other frameworks, the article explores the idea that participation doesn’t always guarantee engagement. The quality of engagement is a direct result of the goal of the process and the amount of psychological safety present. This analysis got me thinking about creating a scale of participation to bring to life the variety seen in AARs and is designed to help those leading AARs to be clear on the what their goals are. This table below sets out the five levels of participation that I’ve developed. Involve, Facilitate and Empower are all possible and healthy uses of the After Action Review approach. Organisational requirements will impact on how the AAR approach is deployed in each context and the full “Empower” approach where AAR participants are given full scope to act on the learning and their own recommendations, may not be appropriate for AARs taking place within a PSIRF governed process. However, it is a legitimate and valuable approach in project teams and other contexts. The continuum When you look at the continuum, you can see there is a shift from left to right of the AAR Conductor having knowledge of the event to needing to have very little. The Inform position is one where the AAR Conductor already has knowledge and is inviting participants to contribute to enrich the knowledge already held. This is not genuine engagement and along with the Consult approach, can be experienced as a tokenistic application of the AAR. The Facilitate and Empower positions, are those where the AAR Conductor needs have little knowledge prior to the AAR since the work is centred around the participants’ contributions and responses the AAR questions alone. This ensures meaningful engagement with the participants and requires skill in creating the psychological safety for honest conversations and asking the searching questions. The Empower position is different in that the aim is not to hand back the responsibility for action and reporting to the AAR Conductor, but to enable the participants to be ready to take the learning forward. Examples of the types of questions asked along the continuum Inform – “Did you have enough staff on duty?”, “ Was the NatSSIPS process followed?” Consult – “How did the patient respond?”, “Why weren’t the police called?” Involve – “What else was happening on the ward at the time?”, “What might prevent this happening again?” Facilitate – “Communication between agencies has been mentioned a few times: what might improve communication between agencies in future?” “Which of these ideas would make most impact?” Empower – “What do you want to do with this learning?” What support do you need to put this into action?” In summary As an AAR Conductor, you have to operate within your organisations’ context but it is vital to build trust in the AAR process. You will do this by ensuring your actions match your stated intentions and you are transparent about the level of participation you’re aiming for. Getting this right isn’t just about the integrity and standardisation of the AAR approach, it is also about maximising the potential for improvements in patient safety. Those AARs where Involving, Facilitating and Empowering are the goal, increase the level of accountability for change owned by the participants. We know from the research that when staff are fully engaged in the AARs they attend, their behaviour changes and patients are safer as a result.- Posted
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After Action Review (AAR) is a debriefing methodology for learning from events. The method is a facilitated discussion among a team exploring what they expected to happen, what did happen, and what they learned. Ireland’s Health Service Executive includes the AAR methodology as part of its national Incident Management Framework. This paper explores enablers and barriers to AAR implementation in an Irish tertiary specialist hospital.- Posted
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The aim of this study was to investigate the effect of After Action Review on safety culture and second victim experience and to examine After Action Review implementation in a hospital setting.- Posted
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This guidance aims to provide an overview and an understanding and the benefits of AAR and advice to assist with its introduction and implementation within services so that it adds value and is sustainable.- Posted
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The After Action Review (AAR) summary report template has been co-designed by NHS England, the Health Services Safety Investigations Body and staff leading AARs in a range of healthcare organisations. It was developed to standardise the reporting of AARs. It is not intended to be an AAR facilitation guide. The structure is purposefully simple so that AARs can focus on reflective conversation and do not become a bureaucratic documentation exercise. This structure will continue to be evaluated and developed in response to feedback and learning about its use in practice.- Posted
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The Health Services Safety Investigations Body (HSSIB) run a half-day 'Introduction to After Action Review (AAR)' course for healthcare staff.- Posted
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If one person praises or compliments another individual or service in a formal debrief situation, alarm bells should be ringing. Yes, I know it seems counter intuitive to suggest that offering positive feedback might have a negative side to it in a debrief. Surely everyone needs to receive praise and compliments and feel good about what they’ve done? Whilst that may be true in many other situations, in a debrief context, such as an After Action Review (AAR), praise is a like Trojan Horse. It looks like it is one thing but carries with it many other meanings as well as opportunities .Praise isn’t all bad in a debrief or AAR, as its usually an indicator that there is something valuable to explore so it shouldn’t be ignored but it must be handled as sensitively as blame. -
Content Article
In this LinkedIn blog, Judy Walker outlines four ways that After Action Reviews (AARs) differ from more informal 'Lessons Learned' events, and how AARs can result in more effective learning. She also highlights four topics that organisations affected by recent cyberattacks can explore in AARs: Leadership and co-ordination - Large cyber-attacks demand that robust command and control structures are switched on, to respond to the initial chaos that inevitably ensues when disasters strike. Large incidents also involve a multitude of agencies, each of which must direct its own resources and co-ordinate with each other. Communications. Systems of command, control, and coordination are predicated on being able to communicate efficiently and requires that people are willing to share information with each other. Planning - Gaps in emergency plans cause serious problems when disaster strikes and weaknesses in plans often go unnoticed because actual plans are not trained fully or exercised realistically. Resilience – AARs should always address what supportive behaviours, processes and structures enabled efficient and effective response and recovery so that these can be repeated and strengthened as required.- Posted
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An After Action Review is a facilitated discussion following an event to understand what happened and why, and how it could be improved from the perspective of those who were involved. There is an emphasise on facilitation of active awareness and self learning to lead to lasting change and improvement. AARs are included as an investigation and learning tool under the Patient Safety Incident Response Framework (PSIRF). The morning will be a hands on interactive masterclass which will develop your skills in conducting an AAR using simulated case study AAR examples and facilitated discussion. The afternoon will focus on case study sessions from experts who are using AAR in practice. Topics will include AAR under the Patient Safety Incident Response Framework (PSIRF), walkthrough case studies of AAR in action, the role of human factors in AAR and delivering change. There will be an extended focus on informing and involving patients in AARs in line with national guidance “Many national reports clearly articulate the importance of engaging with patients, families, and staff appropriately after a patient safety incident and involving them in any subsequent investigation.” NHS England For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/after-action-reviews or email [email protected] Follow on Twitter @HCUK_Clare #AfterActionReviews hub members receive a 20% discount. Email [email protected] for discount code. -
Content Article
The increasing use of After Action Review to facilitate learning after patient safety events is being welcomed by those directly involved but is meeting some resistance from those in governance roles and elsewhere. One reason for this is the dominance of what Jerome Bruner called the “logical scientific mode of thinking”, writes Judy Walker in this LinkedIn post.- Posted
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After Action Review Masterclass
Patient Safety Learning posted an event in Community Calendar
An After Action Review (AAR) is a facilitated discussion following an event to understand what happened and why. AARs involve key stakeholders involved in the incident and provide insight into how improvements could be made to help deliver safer care for patients. The AAR process emphasises the importance of a facilitated approach with all participants encouraged to work collaboratively to identify possible changes and improvements. AARs provide all participants with an opportunity to reflect and consider opportunities for self-learning. AARs are gathering momentum within healthcare particularly since the approach was identified as one of the national learning response methods within NHS England’s Patient Safety Incident Response Framework (PSIRF) documentation. The workshop will commence by looking at a brief history of AAR across the globe and its recent transition as an approach to help healthcare teams better understand their patient safety incidents. The core part of the day will focus on the four questions involved in conducting an effective AAR and learners will be given the chance to put learning into practice by looking at relevant case studies and scenarios in small groups. The day will conclude with an honest assessment of AARs and consider the challenges and benefits of utilising this team approach in a healthcare setting. This course is aimed at those who wish to lead and conduct AAR reviews plus those who are likely to take part in AAR investigations. The facilitators for this course will continue the journey beyond the course itself to support and enable you to develop your skills in AAR when you return to your organisation. This masterclass will enable you to: Understand history of AARs and why they are gathering momentum in healthcare Appreciate what an AAR is and how it differs from other incident investigation methods Identify when it is appropriate to conduct an AAR Examine what skills effective AAR conductors require Understand the four fundamental questions involved in conducting an AAR Develop your AAR skills via a number of case studies and scenarios Consider how human factors can play a part in the AAR process Examine why AAR can be an effective mechanism for change and improvement Discuss the strengths and weaknesses associated with AARs Evaluate where you consider you can gain the most from undertaking AAR Register hub members receive a 20% discount. Email [email protected] for discount code.- Posted
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An After Action Review is a facilitated discussion following an event to understand what happened and why, and how it could be improved from the perspective of those who were involved. There is an emphasise on facilitation of active awareness and self learning to lead to lasting change and improvement. AARs are included as an investigation and learning tool under the Patient Safety Incident Response Framework (PSIRF). https://www.healthcareconferencesuk.co.uk/virtual-online-courses/patient-involvement or email [email protected] Follow this conference on X @HCUK_Clare #AfterActionReviews hub member receive a 20% discount. Email [email protected] for discount code.- Posted
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untilSince the publication of the PSIRF learning response toolkit in Aug 2022 healthcare providers across the NHS in England have been exploring the application of different tools made available for learning and improving following a patient safety event. After Action Review (AAR) is one such tool. In response to feedback from providers, NHS England, HSSIB and AAR experts have produced a draft AAR report template to use to summarise the output of an AAR. This webinar will explain the template design and include some reflections from a provider that has tested the template in practice. The draft template is available on FutureNHS here: AAR Resources - NHS Patient Safety - FutureNHS Collaboration Platform Recordings, slides and Q&As will be made available on Future NHS here: PSIRF Presentations - NHS Patient Safety - FutureNHS Collaboration Platform Audience: PSIRF webinars are open to everyone to attend, including both NHS and arm’s length bodies. Presenters: Tracey Herlihey, NHS England Melanie Ottewill, HSSIB Judy Walker, AAR expert Jane Carthey, Human Factors and Patient Safety expert Gabby Walters, Royal London and Mile End Hospitals Register- Posted
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After Action Review Masterclass
Sam posted an event in Community Calendar
An After Action Review (AAR) is a facilitated discussion following an event to understand what happened and why. AARs involve key stakeholders involved in the incident and provide insight into how improvements could be made to help deliver safer care for patients. The AAR process emphasises the importance of a facilitated approach with all participants encouraged to work collaboratively to identify possible changes and improvements. AARs provide all participants with an opportunity to reflect and consider opportunities for self-learning. AARs are gathering momentum within healthcare particularly since the approach was identified as one of the national learning response methods within NHS England’s Patient Safety Incident Response Framework (PSIRF) documentation. The workshop will commence by looking at a brief history of AAR across the globe and its recent transition as an approach to help healthcare teams better understand their patient safety incidents. The core part of the day will focus on the four questions involved in conducting an effective AAR and learners will be given the chance to put learning into practice by looking at relevant case studies and scenarios in small groups. The day will conclude with an honest assessment of AARs and consider the challenges and benefits of utilising this team approach in a healthcare setting. This course is aimed at those who wish to lead and conduct AAR reviews plus those who are likely to take part in AAR investigations. The facilitators for this course will continue the journey beyond the course itself to support and enable you to develop your skills in AAR when you return to your organisation. This masterclass will enable you to: Understand history of AARs and why they are gathering momentum in healthcare Appreciate what an AAR is and how it differs from other incident investigation methods Identify when it is appropriate to conduct an AAR Examine what skills effective AAR conductors require Understand the four fundamental questions involved in conducting an AAR Develop your AAR skills via a number of case studies and scenarios Consider how human factors can play a part in the AAR process Examine why AAR can be an effective mechanism for change and improvement Discuss the strengths and weaknesses associated with AARs Evaluate where you consider you can gain the most from undertaking AAR. Register hub members receive a 20% discount. Email [email protected] for the discount code. -
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HSSIB: After Action Review
Sam posted an event in Community Calendar
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- Posted
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HSSIB: After Action Review
Sam posted an event in Community Calendar
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- Posted
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HSSIB: After Action Review
Sam posted an event in Community Calendar
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- Posted
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HSSIB: After Action Review
Sam posted an event in Community Calendar
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- Posted
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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. Autumn marks the deadline for all NHS trusts in England to transition to PSIRF, so it was fitting that our PSMN meeting on 1st September dealt with some of the key issues the new framework is presenting. Patient safety colleagues from a wide range of organisations shared their reflections, concerns and questions about the complex and pressing issues they are facing as they seek to adopt PSIRF’s new approaches to patient safety incident responses. There were rich discussions about variation in how trusts are implementing the framework, the resource implications of meeting the expectations of NHSE regarding PSIRF, how patients engage with the process and who should work with them. Perhaps the most important question that was discussed was about the purpose of patient safety investigations—families may have very different ideas to managers or incident investigation teams about why a loved one’s death should be investigated, and that can hugely affect how they respond to and experience the process. What are the implications of increasing engagement with families and patients? PSIRF introduces a range of new approaches to incident investigation, aiming to make the process shorter and simpler, more collaborative and transparent, and easier to implement learning from. Trusts’ existing patient safety structures and teams will need to adapt to significantly different ways of working under PSIRF. One of the key topics was how to highlight and deal with the consequences of these changes, some of which have been predicted and some of which have possibly not yet been considered by NHS England and individual trusts. Here are some of the implications that members highlighted: There is a resourcing and capacity issue linked to the increased work involved in engaging with families. For example, some organisations are separating the role of engaging with patients and families from that of undertaking investigations, to reflect different staff positions, experiences and skill sets. Across some organisations there is a huge gap in family liaison and support, and that extends to PSIRF. This is a significant resourcing issue that needs to be addressed, as without adequate communication and support, investigations can be very distressing for patients. Different ways of working will require changes and updates to trusts’ technology. For example, some trusts are designing trackers to record and monitor engagement with patients and families by multiple staff members. While this should improve communications between staff and patients, trusts may need to invest in digital and other solutions to make sure systems are reliable and that staff know how and when to use them. Does the language and approach of PSIRF create barriers for patients? The discussion then moved on to the fact that how we engage with patients and families can compound the harm they have already experienced. Working with harmed patients isn’t easy and needs the right people, equipped with right skills and the right resources. Many members voiced the need for more guidance and training for all clinical staff, as PSIRF means that their role in investigations and patient engagement is changing. For example, some organisations are updating their Duty of Candour policy to reflect the requirements of PSIRF, and these changes will affect all clinical staff. During the discussion, several members pointed to incidents where families had found the approach and language of PSIRF difficult, or even offensive. There was some discussion about how the language used is a barrier to patient engagement, with names and descriptions in the framework laden with what is being seen as NHS jargon such as ‘learning leads’ and ‘patient safety partners’. Members pointed out that this language is inaccessible and doesn’t make it easy for patients to understand what’s going on in the investigation process. One member suggested learning from the way the Parliamentary and Health Service Ombudsman has used accessible language in its new NHS Complaints Standards. Several members reported instances where families had found the language of PSIRF insensitive. For example, one family member had told a member of staff, “my mother’s death is not a learning opportunity.” Perceptions that the investigation process is detached from the reality of a person’s lived experience can lead to difficulties in maintaining supportive and positive relationships with patients and families. It highlights a need to consider whether the language used in the implementation of PSIRF is adequately compassionate and respectful. We also talked about when the best time to involve patients in different PSIRF processes is. For example, one member pointed out that if you involve patients in an After Action Review (AAR) too early on, then you won’t have any answers for them, and this can be frustrating for everyone involved. On the other hand, conducting an AAR without the patient won’t include the patient's direct insight and might be seen as ‘rehearsing the truth’. This can undermine trust in the transparency of the investigation. We also looked at the resources and literature available for patients engaging with PSIRF, and the general feeling was that there is a big gap here. There is no guidance from families from NHS England, and while some excellent resources have been produced by the Learn Together collaboration, they are quite lengthy, which may put patients off. It was suggested that a summary version of the resources would be a helpful tool to offer patients. What’s the purpose of patient safety investigations? The issues we looked at around the language of PSIRF led on to a broader discussion about why we investigate, and whether PSIRF is aligned with patient views on this. PSIRF places a big emphasis on learning from patient safety incidents, which is clearly vitally important for improving patient safety. However, patients who have been harmed or people who have lost a loved one to avoidable harm are likely to have different reasons for wanting an investigation. The family member previously mentioned, who did not like their mother’s death being referred to as a ‘learning opportunity’, did not see organisational learning as the primary purpose. Patients and families may be looking for: a sense of justice and, in some cases, compensation. compassionate support and clear information on what happened to them or their relative. assurance that changes will be made to prevent future harm. This is a strong motivator for most patients, but it may not be the only reason they want to be involved in the process of investigation. It was also pointed out that the proportionate approach that PSIRF promotes presents us with a big gulf in the nature and approach we take to patient and family engagement. The level of engagement will depend on the severity and impact of avoidable harm, meaning patients involved in incidents that don’t reach the threshold for a patient safety incident investigation (PSII) may not receive the answers and support they need. Staff engagement and support for patient safety specialists As well as the challenges PSIRF presents in terms of patient engagement, the new framework will also require buy-in from staff right across the organisation. Some members shared concerns about attitudes they had encountered in front line clinicians and patient safety leads. For example, it was reported that some doctors are taking the view that if no AAR is submitted, they don’t need to have a Duty of Candour discussion with patients or families. One very important question we discussed was what additional support might be needed for staff who conduct investigations or work in patient safety roles. Exposure to traumatic events and awful harm, day in and day out, is painful and causes harm in itself. There is a clear gap here; dealing with patient safety incidents can be emotionally draining, and we talked about the need for clinical supervision and psychological support for staff. At past PSMN meetings we have discussed at length the need to provide support and resources for harmed patients and their families. It is an important area that we will return to at future meetings. Variation between trusts The key theme that ran throughout the session was variation in how different organisations are implementing PSIRF. Each organisation’s culture and commitment to patients and family involvement will be an important factor in how PSIRF is implemented. While some organisations have a strong base on which to implement PSIRF patient engagement recommendations, others don’t. Some of the key variations discussed include: different practical approaches to engagement. Some trusts will have informal discussions with families, while others undertake more formal reviews and investigations. a wide range of structures across patient safety teams, with roles carrying different responsibilities from trust to trust. differences in how tools are applied. For example, some trusts are using AARs to assess how effective the investigation process is, while others are using them as a learning response directly. Some trusts are involving patients directly in AARs, while others are using their Patient Engagement Leads as the patient representative in the process. Patient Safety Partners have different levels of involvement in learning responses. PSIRF was deliberately designed to allow trusts to adapt their approaches according to their own contexts, which means that variation is an inevitable part of PSIRF implementation. However, members of the PSMN are expressing concern about how this will exacerbate inequities for patients based on where they happen to live—an incident that qualifies for an AAR in one trust may not qualify in others. Reflections on the way forward These wide-ranging issues feel like a lot to try and deal with while doing the day-to-day work of patient safety management. But as one colleague pointed out, there has been little funding or training on these complex issues, and members shouldn’t be too hard on themselves. There is a long way to go before PSIRF makes tangible improvements to the methods and outcomes of learning responses and incident investigations, for both patients and staff. It was highlighted that research and evaluation funding to consider dissemination and implementation is available for another year and members should consider how they might access and use this to look at tackling some of these key issues. Joining the Patient Safety Management Network Do you work in patient safety and want to join the Patient Safety Management Network? You can join by signing up to the hub today. If you are already a member of the hub, please email [email protected].- Posted
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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.- Posted
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Content Article
These templates were developed by Liverpool Heart and Chest Hospital for use in After Action Review, SWARM and Rapid Review toolkit responses.- Posted
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In this blog, After Action Review (AAR) specialist Judy Walker shares an account of a successful AAR that took place amongst a surgical team. The AAR was called after a near-miss where the anaesthetist was prevented from injecting spinal block medication into the wrong side of a patient's spine by an operating department practitioner (ODP). The story demonstrates the benefits of AAR, including accelerated learning, a no-blame approach, flattening staff hierarchy and a significant reduction in the time it takes to investigate an incident. Related reading Patient Safety Spotlight interview with Judy Walker, Senior Business Consultant, iTS Leadership Disaster recovery: restoring hope after things go wrong (Judy Walker, 5 January 2023)- Posted
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