Patient Safety Incident Investigation Training
Systems Approach to Learning from Patient Safety Incidents Workshop (Lot 4a)
Duration
2 or 3 days
Delivery
Online or in-person
Delegates
Up to 12
We deliver practical patient safety investigation courses centred around safety science and systems thinking principles, using methods that teach attendees how to investigate. For our interview simulation session we use two facilitators. This allows us to focus on every delegate to ensure they have individual feedback. Our courses are currently mostly delivered in an online format (e.g. via Microsoft Teams/Zoom) at times to suit your staff and can also be delivered in separate standalone modules as required.
Content is based around a serious incident case study, that delegates will investigate, and includes:
- Planning an investigation, including interview/consultation/observation planning and duty of candour.
- Data gathering, including live interview practice for all delegates, recording evidence and developing initial chronologies/timelines.
- Analysis of evidence, including systems-based approaches (e.g. SEIPS, swim lanes).
- Report writing, in plain English, that is factual, impartial, and focused on systemic factors. This includes development of key findings and effective improvement-based recommendations.
- Best practice safety action development, in line with systems-thinking.
- Debriefs and after-action reviews, monitoring, and measurement.
The Patient Safety Incident Investigation Course training outcomes are:
Practical skills in all aspects of investigation from planning to recommendation writing and:
- Understanding why decisions made sense at the time for staff (local rationality principle) to avoid counterfactual reasoning (the hindsight bias of could/should have).
- Improved human-systemic-factors awareness that fosters supportive family and staff engagement.
- Understanding the role of an investigator in promoting Just Culture by reducing pejorative thinking and writing.
- Enhanced knowledge of the ‘NHS national standards of patient safety investigation guiding principles’.
The full skills-based course is recommended to be 3 days, delivered over consecutive days or in a modular format as required. Shorter courses are available for a minimum of 2 days which offer a lower level of practical experience in interviewing and report writing practice.
As this is a skills-based course, numbers are capped at 12 delegates to allow us to observe and give supportive feedback to individuals on their interviewing, analysis, and report writing.
For bookings, fees, and further information contact our patient safety training team via email: pstraining@systemicfactors.com.
Looking for a different course?
Take a look at the other Patient Safety courses we offer.