Course Overview
This virtual 2-day training session will focus on the first crucial steps of any incident investigation. The emphasis will be on practicality and a process that can be incorporated into the health professional’s working day, as well as one that can be conducted remotely. In line with the new Patient Safety Strategy delegates will be taught how to identify both good practice and care delivery problems will along with their contributory factors. The session includes modules on Information Collection and Organisation, Human Factors, Precision Writing and the production of SMART recommendations.
Delegates will be provided with a suite of templates to use during an investigation as part of our commitment to an holistic approach to patient safety.
Delegates will learn:
- How much information to gather and how to gather it
- The role of human factors and ergonomics in patient safety incidents
- How to involve patients, families and carers
- How to organise evidence using Timelines
- How to critically analyse evidence
- How to conduct interviews with staff members and families
- A guide to precision writing
- Identification of good practice
- Identification of care delivery problems
- Identification of contributory factors
- Identification of broken and missing systems
- The key elements of SMART recommendations
- How to pull the final report together
Course Timetable
Day 1
| 9.00am to 09.15am | Logon, technical knowhow and introductions |
| 09.15am to 09.30am | Overview of the investigation methodology. |
| 09.30am to 9.45am | Human factors and ergonomics; this session will explore how human factors can influence an investigator’s approach, the importance of objectivity and tips for achieving neutrality. |
| 9.45am to 10.15am | Gathering information; a report is only as good as the information it is based on. Investigators must beyond simply gathering evidence to find out ‘what’ happened – they must find and ‘why’ it happened and remember to gather human factors and ergonomic evidence. This will ensure that Investigators possess enough evidence to make SMART recommendations. |
| 10.15am to 10.30am | Coffee Break |
| 10.30am to 11.15am | Mapping the information using simple and tabular timelines. |
| 11.15am to 11.45am | Critical Analytical Skills – How to identify missing or incomplete evidence |
| 11.45am to 12.00pm | Conclusion, Questions and Set up for Module 2 |
| 12.00pm to 1.00pm | Lunch |
| 1.00pm to 1.15pm | Recap on Module 1 |
| 1.15pm to 1.45pm | Critical Analytical skills – how to prepare for interviews. How to conduct interviews with staff members and families |
| 1.45pm to 2.30pm | Identification of good practice and care delivery problems. The importance of standards and precision writing. |
| 2.30pm to 2.45pm | Tea Break |
| 2.45pm to 3.15pm | Identifying contributory factors, including human factors and broken and missing systems using wagon wheel and barrier analysis. |
| 3.15pm to 3.45pm | Focus on writing excellent recommendations, benchmarking, reasonable/measurable action plans and producing standardised reports. Example report format provided. |
| 3.45pm to 4.00pm | Summary, questions, conclusion and feedback |
Day 2
| 9.00am to 09.15am | Logon, technical knowhow and introductions |
| 9.15am to 10.15am | Witness statement case study |
| 10.15am to 10.30am | Coffee Break |
| 10.30am to 12.00pm | Planning for interview. Question drafting case study |
| 12.00pm to 1.00pm | Lunch |
| 1.00pm to 2.30pm | Incident Investigation case study from start to finish. Reports will be submitted to and marked by the trainers. |
| 2.30pm to 2.45pm | Tea Break |
| 2.45pm to 3.15pm | Case study continued. |
| 3.15pm to 3.45pm | Delegates receive feedback on their incident investigation reports. |
| 3.45pm to 4.00pm | Summary, questions, conclusion and feedback |
