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Found 29 results
  1. Content Article
    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)
  2. 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
  3. Content Article
    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 to be set up to support the AAR approach to learning with leaders championing the process and the practice and believing in the value of organisational learning. “The After Action Review has democratised the Army. It has instilled a discipline of relentlessly questioning everything we do. Above all, it has re-socialised many generations of officers to move away from a command and control style of leadership to one that takes advantage of distributed intelligence.” Pascale, Millemann and Gioja, 20001 We can learn much from the military’s use of AAR. The problems created by its hierarchical structure are similar to ours in medicine, especially the fear of the consequences of speaking out and voicing a different opinion to your superiors. Research confirms that junior staff are often reluctant to question the direction or decisions of their seniors, even when they feared patients were at risk of harm.2 Fear of the consequences also limits open and honest reporting of incidents, restricting the potential gains of learning at the system-wide level and at the local level. Yet consistent and widespread use of AAR in battlefield and training environments has reduced the fear of blame and retribution and increased effective communication through the ranks and transformed the speed and value gained from learning. It has done this in part because every AAR creates a safe environment for learning due to the actions of the AAR Conductor and the organisational commitment to using AAR. Professor Amy Edmondson has spent over 20 years researching the components of effective 'work groups' and summarises what increases team performance as "psychological safety". It can be defined as "being able to show and employ one's self without fear of negative consequences of self-image, status or career".3 High levels of psychological safety in clinical teams have numerous benefits for safe and effective care.4 My experience has taught me that with repeated and regular use of AAR, the psychological safety experienced during them, shapes and influences behaviour positively outside of them. Another reason AAR works to improve patient safety is the quality of the learning and changes in behaviour coming out of them. Here the research is also very clear. A meta-analysis of research into AARs5 demonstrated that the learning coming out of AARs can improve team and individual performance as much as 25% when compared to control groups. This analysis of research in a wide variety of settings showed that participants learnt so effectively through the AARs, that they were able to perform and deliver up to 25% more effectively afterwards. This is because the participants in the AAR are fully involved in their own learning so instead of being talked at, they are being asked to make sense of the shared picture of the event that has been generated in the AAR. The responsibility for learning and change in an AAR, therefore, rests with the participants and is directly relevant to them. In a clinical setting this means that improvements in safety and behaviour can start the minute the AAR ends. Contrast this with an investigation, where the learning is owned by the investigator and the organisation that employs him or her, and the responsibility for change rests far away from those involved in the action. The quality of the shared mental model that is created in the best AARs directly supports learning about patient safety matters as the individual participants access other people’s experiences to gain an overview of an issue. The skilled facilitation by the AAR Conductors is a vital part of this, as once a safe learning environment is established, cognitive biases and prejudices are reduced and clearer thinking is possible. Patient safety learning is also greatly enhanced through AAR because of both its 'learn as you do' approach and the fit with effective adult learning theory models. AARs do not require clinical staff to leave the ward for days at a time for traditional teaching about patient safety. Instead AAR practice makes it possible for learning about patient safety to become an everyday habit and, therefore, more effective. Since the AAR process allows individuals to learn for themselves what happened and what got in the way or enhanced safe, effective care, it is mapped onto the individuals own knowledge base and makes a more lasting impact. The last feature of the issues highlighted in the NHS Long Term Plan concerning patient safety was the workforce. My experience of facilitating hundreds of AARs in clinical settings has highlighted its potential to reduce the stress levels of staff as the supportive no-blame environment encourages greater clarity and less personal blame. Lower stress levels will have an indirect but valuable effect on staffing levels as sickness absence may be reduced and retention boosted. This is just a summary of some of the features of the AAR approach which I know will enhance patient safety. Other AAR Conductors will have more insights to share, and the academic researchers in the US and Israel universities many more. I would love to discuss AARs further with you, contact me at: judy.walker@its-leadership.co.uk References Pascale RT, Millemann M, Gioja L. Surfing the Edge of Chaos: The Laws of Nature and the New Laws of Business. Three Rivers Press; 2000. Crowe S, Clarke N, Brugha R. ‘You do not cross them’: Hierarchy and emotion in doctors' narratives of power relations in specialist training. Social Science & Medicine 2017; 186: 70–77. Kahn WA. (1990-12-01). Psychological Conditions of Personal Engagement and Disengagement at Work". Academy of Management Journal 1990; 33(4): 692–24. doi:10.2307/256287. Edmondson AC, Bohmer RM, Pisano GP. Disrupted routines : Team Learning and New Technology Implementation in Hospitals. Harvard University Administrative Science Quarterly 2001; 46: 685–716. Tannenbaum SI, Cerasoli CP; the Group for Organizational Effectiveness. Do Team and Individual Debriefs Enhance Performance? A Meta-Analysis. Human Factors 2013; 55(No. 1): 231–245.
  4. 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
  5. Content Article
    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 military for use in the NHS. AAR provides a deceptively simple vehicle to structure healthy blame-free team interactions and the aim was to improve patient safety, clinical practice and team behaviours.[2] The AAR approach has since become business as usual at UCLH where it is now widely understood and frequently used. What my colleagues at UCLH recognised so well is that AAR is so much more than the four questions you get when you type After Action Review into a search engine[3] and, thus, designed the introduction of the approach with this in mind. A paper in the Harvard Business Review[4] describes why AAR has so often failed in the corporate environment and this gives useful insights, but I have witnessed three particular challenges in the healthcare setting. 1. Fear The organisational and psychological barriers to being able to talk honestly about errors in multi-professional teams are accentuated by the hierarchical nature of the clinical context. Put simply, this means despite everyone’s best intention to learn from a near-miss or an unexpected event, there will be fear about being fully open in front of those more senior or junior and those from other disciplines. If we are being really honest with ourselves, we know this to be true. Fear of what others think about what we have done, and whether it will affect our standing in some way, is a universal human trait which is increased when the boss is in the room. This fear is in direct tension with the AAR concept of openness and cross-disciplinary learning and will act as a barrier to calling AARs unless leaders act as role models in AARs and set the scene by being honest and open themselves. 2. Blame The emotive nature of clinical care heightens the response when things go wrong meaning the tendency to find something or someone to blame is increased. Not only do we have institutional demands pressing hard for straightforward answers, meaning we look for something obvious to blame, we also have our own human reaction to distance our self from responsibility. This traditional reaction again lies in direct tension with the very idea of AAR, where the process is not to blame but to learn. The research is clear, that in this most complex of operating environments there is rarely a single point of failure or a single individual who is to blame, instead there are multiple causes and effects, which, when better understood, provide a firm place from which to make effective changes. 3. Responsibility The concept of clinical professionalism is centred around the individual’s responsibility to deliver safe effective care and it is rooted in the very foundations of how the NHS was created. Clinicians are raised in the belief that they should know the answers to problems and the whole structure of career progression is based around acquiring more knowledge, research papers and letters after your name. AAR is a process of learning as a group and taking responsibility together to find out how to improve, so it is not surprising that it sits in tension with the historical emphasis on the individual healthcare professional and the value of their existing knowledge. AARs allow for the creation of new knowledge through a collaborative process. The joint guidance from the General Medical Council (GMC) and Nursing & Midwifery Council (NMC) on the professional duty of candour states: “Clinical leaders should actively foster a culture of learning and improvement.”[5] AAR is one of the best mechanisms to both foster and drive a culture of learning and improvement, but the simplicity of the AAR process itself should not blind you to the need to be very considered in how you mitigate and manage the barriers in a clinical setting. If you would like to discuss AARs further, I'd love to hear from you. Contact me at: judy.walker@its-leadership.co.uk References Tannenbaum SI, Cerasoli CP. Do team and individual debriefs enhance performance? A meta-analysis. Hum Factors 2013;55(1):231-45. Walker J, Andrews S, Grewcock D, Halligan A. Life in the slow lane: making hospitals safer, slowly but surely. J R Soc Med 2012;105(7):283-7. doi: 10.1258/jrsm.2012.120093. NHS Improvement. Online library of Quality, Service Improvement and Redesign tools: After Action Review. Darling M, Parry C, Moore J. Learning in the Thick of It. Harvard Business Review: July-August 2005 issue. Nursing and Midwifery Council. Openness and honesty when things go wrong: the professional duty of candour. June 2015. Read Judy's previous blog: How can After Action Reviews improve patient safety?
  6. Content Article
    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.
  7. 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
  8. 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 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.
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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. 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?
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    Suggested reading: Innovation requires restraints (Judy Walker, 10 May 2021) Why isn’t After Action Review used more widely in the NHS? What can we do to create more open cultures? A blog by Judy Walker (February 2020)
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