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Found 194 results
  1. Event
    until
    This is for those in NHS Trusts in England only. This practical course offers an overview of the principles that underpin a professional safety investigation interview with either a member of staff, a patient or a family. The course aligns to the PSIRF guidance on a systems approach to interviews. The course includes: Planning and preparing for an interview. Using a structured hierarchy of questions to facilitate comprehensive, accurate information. Asking system-focused questions. Closing an interview. Learning objectives Understand and describe the working elements of a standardised and tested approach to investigative interviewing. Understand how to apply the model to plan, conduct and evaluate your investigative interviews. Conduct more ethical and professional interviews. Reach stronger defensible investigation conclusions. Increase your own and others confidence in your ability to investigate complex matters. Register
  2. Event
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    This is for those in NHS Trusts in England only. This practical course offers an overview of the principles that underpin a professional safety investigation interview with either a member of staff, a patient or a family. The course aligns to the PSIRF guidance on a systems approach to interviews. The course includes: Planning and preparing for an interview. Using a structured hierarchy of questions to facilitate comprehensive, accurate information. Asking system-focused questions. Closing an interview. Learning objectives Understand and describe the working elements of a standardised and tested approach to investigative interviewing. Understand how to apply the model to plan, conduct and evaluate your investigative interviews. Conduct more ethical and professional interviews. Reach stronger defensible investigation conclusions. Increase your own and others confidence in your ability to investigate complex matters. Register
  3. Event
    until
    This is for those in NHS Trusts in England only. This practical course offers an overview of the principles that underpin a professional safety investigation interview with either a member of staff, a patient or a family. The course aligns to the PSIRF guidance on a systems approach to interviews. The course includes: Planning and preparing for an interview. Using a structured hierarchy of questions to facilitate comprehensive, accurate information. Asking system-focused questions. Closing an interview. Learning objectives Understand and describe the working elements of a standardised and tested approach to investigative interviewing. Understand how to apply the model to plan, conduct and evaluate your investigative interviews. Conduct more ethical and professional interviews. Reach stronger defensible investigation conclusions. Increase your own and others confidence in your ability to investigate complex matters. Register
  4. Event
    This is for those in NHS Trusts in England only. This session will provide an opportunity to ‘have a go’ and discuss some of the challenges and practical aspects of using thematic analysis for the purpose of learning from patient safety issues. Learning objectives: Define thematic analysis and its key concepts. Understand the relevance of using thematic analysis in the context of healthcare safety learning responses. Code a sample data set and develop themes. Relate the use of thematic analysis to your own safety learning response practice. Registration
  5. Event
    This is for those in NHS Trusts in England only. This session will provide an opportunity to ‘have a go’ and discuss some of the challenges and practical aspects of using thematic analysis for the purpose of learning from patient safety issues. Learning objectives: Define thematic analysis and its key concepts. Understand the relevance of using thematic analysis in the context of healthcare safety learning responses. Code a sample data set and develop themes. Relate the use of thematic analysis to your own safety learning response practice. Register
  6. Event
    This is for those in NHS Trusts in England only. This session will provide an opportunity to ‘have a go’ and discuss some of the challenges and practical aspects of using thematic analysis for the purpose of learning from patient safety issues. Learning objectives: Define thematic analysis and its key concepts. Understand the relevance of using thematic analysis in the context of healthcare safety learning responses. Code a sample data set and develop themes. Relate the use of thematic analysis to your own safety learning response practice. Register
  7. Event
    This is for those in NHS Trusts in England only. This session will provide an opportunity to ‘have a go’ and discuss some of the challenges and practical aspects of using thematic analysis for the purpose of learning from patient safety issues. Learning objectives: Define thematic analysis and its key concepts. Understand the relevance of using thematic analysis in the context of healthcare safety learning responses. Code a sample data set and develop themes. Relate the use of thematic analysis to your own safety learning response practice. Register
  8. Event
    This is for those in NHS Trusts in England only. This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course is includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. Learning objectives: Define what After Action Review is. Understand the principles of After Action Review. Know the attributes needed to be an After Action Review facilitator. Understand how to conduct an After Action Review. Register
  9. Event
    This is for those in NHS Trusts in England only. This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course is includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. Learning objectives: Define what After Action Review is. Understand the principles of After Action Review. Know the attributes needed to be an After Action Review facilitator. Understand how to conduct an After Action Review. Register
  10. Event
    This is for those in NHS Trusts in England only. This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course is includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. Learning objectives: Define what After Action Review is. Understand the principles of After Action Review. Know the attributes needed to be an After Action Review facilitator. Understand how to conduct an After Action Review. Register
  11. Event
    This is for those in NHS Trusts in England only. This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course is includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. Learning objectives: Define what After Action Review is. Understand the principles of After Action Review. Know the attributes needed to be an After Action Review facilitator. Understand how to conduct an After Action Review. Register
  12. Event
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    The Patient Safety Incident Response Framework (PSIRF) is the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents and ensuring learning and improvement in patient safety. This national conference looks at the practicalities of implementing and using PSIRF. The day will provide an update on best practice in incident investigation under PSIRF and ensuring the focus is on a systems based approach to learning from patient safety incidents and delivering safety actions for improvement. The PSIRF is a contractual requirement under the NHS Standard Contract and as such is mandatory for services provided under that contract, including acute, ambulance, mental health, and community healthcare providers. This includes maternity and all specialised services. Book your place
  13. Content Article
    One way to understand the links between unwanted events, conditions and interventions is via causal loop diagrams. These represent how situations perpetuate in 'causal loops'. They are depicted as words and phrases for events and conditions, and arrows with a plus or minus sign to indicate the direction of causal influence. Causal loop diagrams can assist a conversation via the gradual building of each loop. They can otherwise represent data from research and practice.  Steven Shorrock illustrate the progressive build of a causal loop diagram concerning reactions to unwanted events, including fixes that fail, based on practice and research. This might be useful to professionals seeking to understand why unwanted events continue to occur despite, or because of, interventions. The diagram is not ‘complete’ and would be drawn differently for different purposes, contexts and situations.
  14. Content Article
    The leadership and management functions of Patient Safety Incident Response Framework (PSIRF) oversight are wider and more multifaceted compared to previous response approaches. When working under PSIRF, NHS providers, integrated care boards (ICBs) and regulators should design their systems for oversight “in a way that allows organisations to demonstrate [improvement], rather than compliance with prescriptive, centrally mandated measures”. To achieve this, organisations must look carefully not only at what they need to improve but also what they need to stop doing (eg panels to declare or review Serious Incident investigations). Oversight of patient safety incident response has traditionally included activity to hold provider organisations to account for the quality of their patient safety incident investigation reports. Oversight under PSIRF focuses on engagement and empowerment rather than the more traditional command and control. 
  15. Content Article
    NHS England is introducing a new approach to investigating patient safety incidents, called the Patient Safety Incident Response Framework (PSIRF). To help organisations develop their plans and transition to this new way of working, Patient Safety Learning has published a template PSIRF Risk Register and Risk Management Plan.
  16. Event
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    This popular training day covers the must-dos and the grey areas around the statutory Duty of Candour, with a strong emphasis on going beyond mere compliance and delivering the duty of candour in a meaningful way for patients and families and for the staff involved and the organisation. It has been updated to directly support the successful implementation of the PSIRF guidance and the ‘Harmed Patient Pathway’. The training is delivered by Peter Walsh, the ex-Chief Executive of AvMA, who is well known for his pioneering work on the Duty of Candour, and Carolyn Cleveland, who specialises in training professionals in dealing with difficult emotions and conversations and doing so with empathy, understanding perspectives. Prices: £245 (plus vat) per person. Discounted rate for bookings of 3 or more: £220 (plus vat) per person AvMA is offering a 10% discount for delegates referred via the hub. Use code: DoC-Hub-10 Register for the training Training can also be delivered in-house at your organisation, either in person or online. Please enquire for details by emailing paulas@avma.org.uk
  17. Content Article
    The systems engineering initiative for patient safety (SEIPS) is a framework to help us understand outcomes within complex socio-technical systems, like healthcare. SEIPS has developed over a number of academic papers and offers a range of tools that can help an investigator to understand why things happen. Deinniol Owens and Dr Helen Vosper highlight how SEIPS can be the investigator’s ‘swiss army knife’ when planning and undertaking patient safety investigations.
  18. Event
    The Patient Safety Incident Response Framework (PSIRF) arguably represents the most significant change to investigating and managing patient safety incidents in the history of the NHS. To embed PSIRF effectively within organisations, healthcare teams need to understand and utilise a range of new techniques and disciplines. Clinical audit is an established quality improvement methodology that is often overlooked by patient safety teams, but will play an increasingly important role in ensuring that PSIRF fully delivers its stated objectives. CQC reports often highlight the importance of clinical audit as a measurement and assurance tool that can raise red flags if used appropriately. Indeed, both the Ockenden and Kirkup reports highlighted the importance of clinical audit in identifying and quantifying substandard care. While SEIPS, After Action Reviews, more in-depth interviewing techniques, etc. are all receiving much fanfare in relation to PSIRF, the importance of clinical audit needs to be better understood. This short course will explain how organisations who use clinical audit effectively will increase patient safety and better understand why incidents take place. We will look at the key role of audit in understanding work as imagined and works as done and show why national audits can assist with creating patient safety plans. Change analysis and the effective implementation of safety actions are keys to PSIRF delivery and clinical audit will assist in the delivery of both. We will also demonstrate the important, but often under-appreciated role, clinical audit staff will have in the successful delivery of PSIRF. Key learning outcomes: Why clinical audit is an integral element of PSIRF. Why clinical audit staff have a vital role to play in PSIRF. How clinical audit data can help raise red flags and spot risks. Using clinical audit to better understand your incidents. Ensuring your safety actions are working. Using audit to assess your patient safety incident investigations. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
  19. Event
    This virtual masterclass will build confidence in compassionately engaging and involving families and loved ones to work within the requirements of PSIRF and the Complaints Standards Framework. But more than this, the masterclass will support staff to go beyond compliance to understand the issues and emotional component on a deeper level; to have real authentic engagement and involvement with patients and families. New frameworks such as PSIRF are now in place, but how do we not only comply with these, but go beyond compliance to have real authentic compassionate engagement and involvement with patients, families and indeed staff to make a real positive difference? Connecting new knowledge with emotions can really support long term learning, which is an important part of this masterclass. This one-day masterclass will look at the new PSIRF and the Complaints Standards Framework and through real life content, bringing the human focus for the patients, loved ones, and indeed staff to the forefront. It will support staff to explore what compassionate engagement looks like, feels like, and how to communicate it authentically and meaningfully. In a supportive and relaxed environment, delegates will have the opportunity to gain in depth knowledge of the emotional component, relate to, analyse and realise the significance of and believe in their own abilities in creating practices that not only support the PSIRF but go beyond compliance to be working in a way that supports gaining an optimum outcome for patients, families and staff, in often a less than optimum situation. Key learning objectives: Feel, analyse, and explore the presence and absence of compassionate engagement within life, trauma, and a healthcare incident and how empathy is the gateway to compassion. Seeing perspectives and understanding emotional motivations and the emotional component recognising vulnerability in others and self. Seeing the bigger picture and having an enquiring mind to understand the story and how the ‘Funnel of Life’ can impact on our ability to engage. Build confidence in the positive impact of compassionate engagement and really being authentically interested in the emotional component to be able to create an optimum outcome in often a less than optimum situation. Explore and have a good grasp of how internal unconscious belief systems, can link through to the outcomes we achieve. We know what works with compassionate engagement, but why do we so often struggle? Explore and analyse biases, judgments, and how a lack of compassionate engagement not only has the potential to cause psychological harm, but can prevent optimum outcomes for the organisation. Realise the significance of authenticity rather than feeling fearful of not doing things perfectly. Examine where can we get emotional information from to support us, even if we are not aware we are doing it! Identify the importance of an enquiring mind and a hypothesis as we try and understand the story that we are aiming to compassionately engage with. Develop understanding of Safeguarded Personal Resolution (SPR ®) to formulate compassionate engagement under PSIRF and the Complaints Standards Framework. Develop awareness on personal wellbeing and resilience. Register hub members receive a 20% discount. Email info@pslhub.org for the discount code.
  20. Event
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    The Patient Safety Incident Response Framework (PSIRF) sets out a new approach to learning and improving following patient safety incidents across the NHS in England. PSIRF embedding webinars will feature presentations from NHS organisations and will focus on sharing experiences, adaptions and learning as the designed systems and processes put in place prior to transition are operationalised. Recordings, slides and Q&As from our transition webinars series can be found on Future NHS alongside other workshops and supplementary materials and resources: PSIRF Presentations - NHS Patient Safety - FutureNHS Collaboration Platform Audience: Embedding webinars are open to everyone to attend, including both NHS and arm’s length bodies. Presenters: Tracey Herlihey, Head of Patient Safety Incident Response, NHS England Further speakers TBC Register
  21. Content Article
    Professor Joe McDonald, Principal Associate for health system collaboration for Ethical Healthcare Consulting, explains how the recent trial of Lucy Letby triggered both personal and professional rage – and the desire to do more to keep patients safe across the NHS.
  22. Content Article
    Innovation in the education and training of healthcare staff is required to support complementary approaches to learning from patient safety and everyday events in healthcare. Debriefing is a commonly used learning tool in healthcare education but not in clinical practice, but little is known about how to implement debriefing as an approach to safety learning across a health system. After action review (AAR) is a debriefing approach designed to help groups come to a shared mental model about what happened, why it happened and to identify learning and improvement. This paper describes a digital-based implementation strategy adapted to the Irish healthcare system to promote AAR uptake. The digital strategy aims to assist implementation of national level incident management policies and was collaboratively developed by the RCSI University of Medicine and Health Sciences and the National Quality and Patient Safety Directorate of the Health Service Executive. During the Covid-19 pandemic, a well-established in-person AAR training programme was disrupted and this led to the development of a series of open access videos on AAR facilitation skills (which can be accessed via the link to the paper). These provide: an introduction to the AAR facilitation process a simulation of a facilitated formal AAR techniques for handling challenging situations that may arise in an AAR reflection on the benefits of the AAR process. These have the potential to be used widely to support learning from patient safety and everyday events including excellent care.
  23. Content Article
    In this blog, Patient Safety Learning’s Chief Executive Helen Hughes reflects on the charity’s work and some of the key patient safety developments in the past 12 months and looks ahead to 2024.
  24. Content Article
    A patient safety incident investigation (PSII) is undertaken when an incident or near-miss indicates significant patient safety risks and potential for new learning. Investigations explore decisions or actions as they relate to the situation. The method is based on the premise that actions or decisions are consequences, not causes, and is guided by the principle that people are well intentioned and strive to do the best they can. The goal is to understand why an action and/or decision was deemed appropriate by those involved at the time.  This NHS England document provides an overview of patient safety incident investigation stages, tips and suggested structure for analysis.
  25. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Tracey talks about how her lived experience of navigating the criminal justice and healthcare systems as a victim of serious violent crime has shaped her role as a Patient Safety Partner. Tracey is passionate about speaking up for patients and families, and she highlights the need to prevent compounded trauma by ensuring services meet their needs. She calls for a more joined-up approach between public services and outlines the importance of clear, compassionate communication following a patient safety incident or other traumatic event.
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