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Systems Based Approach to learning from Patient Safety incidents - 3 day

Duration: 19.5 Hours over 3 days
Accreditation: 18 CPD

This course is for Learning Response Leads and follows the competencies required in the Patient Safety Incident Response Standards 2022 and has and a more in-depth review of how to conduct a serious safety response using a systems-based approach within a health and social care setting.

The course follows and endorses current NHS Patient Safety Incident Investigation (PSII) guidance and teaches recognised good practice approach(es) to systems based PSIIs.

This three-day intensive masterclass will provide Investigation Skills Analysis Training in line with the Patient Safety Strategy and subsequent guidance and course focus is on understanding that healthcare systems that are founded on human factors principles can positively impact on safety by:

  • Reduction of harm through better design of healthcare systems and equipment
  • Understanding why staff may make errors and how “systems and human factors’ threaten safety.
  • Enhancing teamwork and improving communication between healthcare staff.
  • Improving how we learn when things go wrong by improving current approaches to incident investigation.

This course is designed to provide delegates with the tools and knowledge required to begin leading healthcare investigations. It also strives to examine the difficulties with this process and the importance of placing human factors at the heart of incident investigation.

The course will offer a practical guide to Investigation management with a focus on systems-based patient safety investigation as proposed by the National Patient Safety Incident Response Framework which emphasises the requirement for investigations to be led by those with safety investigation training and expertise, and with dedicated time and resource to complete the work. The course is based around case scenarios and on developing the practical skills required to undertake investigations whilst considering Human Factors and supporting families and staff as well as service users.

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Systems Based Approach to learning from Patient Safety incidents - 3 day

Accredited by:CPD

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Programme Objectives

  • To develop an understanding of the PSIRF framework and to learn key concepts and terms involved in the new Patient Incident Response Framework
  • An understanding of complex systems, systems thinking and understand how Safety II can be integrated into an incident investigation.
  • To understand the impact of Human Factors on adverse events and how those influence quality and safety of care
  • Understands how to distinguish between systems-based failures in safety and the contribution of individual staff.
  • To Understand the importance of being honest and open and the practical application of the duty of Candour
  • To understand the requirements of CQC, and NHS Commissioners
  • To understand the principles of Just Culture and to understands when and how to assess individual culpability as distinct from system failures using NHS just culture guide.
  • Gain an understanding of how to analyse adverse events and near misses that occur to patients in healthcare settings in a way that minimises threat to the staff involved.