Course Summary

Investigating Incidents; a Systems Approach to Learning from Patient Safety Incidents – 2 Day

Organisations are now transitioning over to the Patient Safety Incident Response Framework (PSIRF).  All patient safety incident investigations will have to be undertaken by investigators who have been on a two-day course. This training meets the PSIRF requirements.

This two-day course is delivered virtually via MS Teams or Zoom. It can be delivered face-to-face on request.

The training is practical and case study led, with day one being a non-clinical case study and day two a clinical case study designed to fit the needs of an organisation.

We use breakout rooms for most of the exercises to create a protected learning environment.

Delegates will learn:

  • The purpose and overriding principles of the Patient Safety Incident Response Framework (PSIRF)
  • The different types of learning response prescribed by PSIRF
  • How to undertake a Patient Safety Incident Investigation (PSII)
  • About complex systems, systems thinking and human factors
  • How just culture fits into the patient safety arena
  • The application of the duty of candour
  • How to support and engage with staff, patients, families and carers throughout a learning response
  • How to conduct interviews
  • How to conduct observations in order to understand work as done
  • The additional evidence required
  • Methods of analysis; how to use the SEIPS model and the Contributory Factors Framework
  • The SEIPS work system template
  • How to map and organise evidence
  • How to produce meaningful and actionable safety actions and safety recommendations
  • How to create effective measurement plans
  • Robust and accessible report writing techniques
  • The importance of monitoring the effectiveness of safety actions and recommendations

Course Timetable

Day One

09.00am to 09.30am Logon, technical knowhow and introductions
 09.30am to 10.00amOverview of PSIRF. Different types of learning response. What is a PSII?
10.00am to 10.30am A practical introduction to complex systems, systems thinking and human factors
10.30am to 10.45am Coffee Break
10.45am to 11.15am The importance of neutralising and human factors
11.30am to 12.15pmGathering evidence (including working with patients and their families)
12.15pm to 1.15pmLunch
1.15pm to 2.15pm     Mapping: simple and tabular timelines
2.15pm to 2.30pmTea Break
2.30pm to 3.30pm  Analysis (including SEIPS) and drafting safety actions
3.30pm to 3.45pm      Report writing and the PSIRF PSII template
3.45pm to 4.00pm     Recap and questions

Day Two  

09.00am to 09.15am Recap, housekeeping, timings and overview of the day.
09.15am to 10.30am  Gathering evidence from staff
10.30am to 10.45am Coffee Break
10.45am to 11.15am Interviews and planning questions
11.15am to 11.30am Introduction to clinical case study
12.30pm to 1.30pm  Lunch
1.30pm to 2.15pm     Case study continues
2.15pm to 2.30pm     Tea Break
2.30pm to 3.45pm     Case study continues
3.45pm to 4.00pm     Recap, questions, summary and feedback

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