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If you would like to suggest improvements to the template, please contact the patient safety team so we can continue to review and evaluate its design. The team can be contacted by emailing patientsafety.enquiries@nhs.net
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Learning response review and improvement tool
NHS England is not responsible for content on external websites.
Summary
This tool was originally developed by NHS Scotland. It has been further refined in collaboration with HSSIB and NHS England after being piloted in approximately 20 NHS trusts and healthcare organisations in England.
The ‘Learning Response Review and Improvement Tool’ is intended to be used by:
- Those writing learning response reports following a patient safety incident or complaint, to inform the development of the written report.
- Peer reviewers of written reports to provide constructive feedback on the quality of reports and to learn from the approach of others.
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This document provides an overview of SEIPS, a framework for understanding outcomes within complex socio-technical systems.
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The SEIPS model sets out desired outcomes– what are you aiming to achieve when you deliver patient care?
Four tools are available to help in the initial stages of a learning response:
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Example stakeholder map to illustrate interactions.
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The crafting of precise and clear ToRs for an investigation is a critical stage and will determine the effectiveness and satisfaction with the output from the investigation.
Four guides have been developed to inform a response to a patient safety incident or cluster of incidents:
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This After Action Review (AAR) report template was designed in collaboration with the Health Services Safety Investigations Body, AAR experts, Human factors experts and end users. It incorporates feedback from Patient Safety Partners.
If you would like to suggest improvements to the template, please contact the patient safety team so we can continue to review and evaluate its design. The team can be contacted by emailing patientsafety.enquiries@nhs.net.
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After Action Review - Learning handbook
NHS England is not responsible for content on external websites.
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The multidisciplinary team (MDT) review supports health and social care teams to: identify learning from multiple patient safety incidents; agree the key contributory factors and system gaps in patient safety incidents; explore a safety theme, pathway, or process; and gain insight into ‘work as done’ in a health and social care system.
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A patient safety incident investigation (PSII) is undertaken when an incident or near-miss indicates significant patient safety risks and potential for new learning.
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Swarm-based huddles are used to identify learning from patient safety incidents. Immediately after an incident, staff ‘swarm’ to the site to quickly analyse what happened and how it happened and decide what needs to be done to reduce risk.
Everyday work describes the reality of how work is done and how people performing tasks routinely adjust what they do to match the ever-changing conditions and demands of work.
Four guides are available to support the exploration of everyday work:
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Guidance on planning and conducting interviews as part of a patient safety incident learning response
NHS England is not responsible for content on external websites.
Summary
This guidance has been developed in collaboration with the investigation education team at the Healthcare Safety Investigation Branch (HSIB).
The Patient Safety Incident Response Framework (PSIRF) recommends that learning response leads move away from a reliance on documentation and written statements to listening to the views of those affected through interviews and discussions. This guidance supports staff to conduct empathetic, supportive interviews during learning responses.
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Link analysis visualises the frequency of interactions in a specific location or environment. It can be used to highlight the frequently used paths taken in an environment and those that are critical for safety.
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To achieve a safer healthcare system we must look at work as it is normally done every day. Observations help us get a better understanding of work as done.
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Walkthrough analysis is a structured approach to collecting and analysing information about a task or process or a future development (eg designing a new protocol).
Patient safety risks or broad patient safety issues may benefit from focused improvement efforts rather than further incident responses. Two tools are available to enable organisations to respond:
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These top tips support health and social care staff to carry out thematic reviews, but organisations may take different approaches, depending on the purpose and scope of their review.
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The horizon scanning tool supports health and social care teams to have a forward look at potential or current safety themes and issues
Organisations should follow an integrated process for developing, implementing, and monitoring safety actions. Further information is provided in the following guides:
Two tools are available to support information gathering and synthesis of information:
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Safety action development starts by identifying and agreeing those aspects of the work system where change could reduce risk and potential for harm (ie ‘areas for improvement’ or system issues). Actions to reduce risk (ie safety actions) are then generated in relation to each defined area for improvement. Following this, measures to monitor safety actions and the review steps are defined.
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The SHARE debrief tool supports health and social care teams to engage teams and staff who may be affected by the outcome (ie safety actions) of a learning response.
We hope to share further tools via our PSIRF FutureNHS workspace.
We will also use this workspace to communicate with staff and local stakeholders via the message board. This workspace is available for anyone to join (you don’t need an NHS email). If you’re not a member and would like to join please email NHSps-manager@future.nhs.uk.