Search the hub
Showing results for tags 'After action review'.
-
Event
untilSince the publication of the PSIRF learning response toolkit in Aug 2022 healthcare providers across the NHS in England have been exploring the application of different tools made available for learning and improving following a patient safety event. After Action Review (AAR) is one such tool. In response to feedback from providers, NHS England, HSSIB and AAR experts have produced a draft AAR report template to use to summarise the output of an AAR. This webinar will explain the template design and include some reflections from a provider that has tested the template in practice. The draft template is available on FutureNHS here: AAR Resources - NHS Patient Safety - FutureNHS Collaboration Platform Recordings, slides and Q&As will be made available on Future NHS here: PSIRF Presentations - NHS Patient Safety - FutureNHS Collaboration Platform Audience: PSIRF webinars are open to everyone to attend, including both NHS and arm’s length bodies. Presenters: Tracey Herlihey, NHS England Melanie Ottewill, HSSIB Judy Walker, AAR expert Jane Carthey, Human Factors and Patient Safety expert Gabby Walters, Royal London and Mile End Hospitals Register- Posted
-
- PSIRF
- Patient safety incident
-
(and 1 more)
Tagged with:
-
Event
An After Action Review is a facilitated discussion following an event to understand what happened and why, and how it could be improved from the perspective of those who were involved. There is an emphasise on facilitation of active awareness and self learning to lead to lasting change and improvement. AARs are included as an investigation and learning tool under the Patient Safety Incident Response Framework (PSIRF). https://www.healthcareconferencesuk.co.uk/virtual-online-courses/patient-involvement or email frida@hc-uk.org.uk Follow this conference on X @HCUK_Clare #AfterActionReviews hub member receive a 20% discount. Email info@pslhub.org for discount code.- Posted
-
- PSIRF
- Patient safety incident
-
(and 1 more)
Tagged with:
-
Content Article
This template standardises the reporting of After Action Reviews (AARs). It is not intended to be an AAR facilitation guide. The template has been co-designed with staff leading AARs in a range of healthcare organisations. The structure is purposefully simple so that AARs can focus on reflective conversation and do not become a bureaucratic documentation exercise. This structure will continue to be evaluated and developed by the National Patient Safety Team. It can be downloaded from the attachment below or it's available on FutureNHS within the AAR tool space here: https://future.nhs.uk/NHSps/view?objectId=42826256- Posted
-
- PSIRF
- After action review
- (and 3 more)
-
Event
After Action Review Masterclass
Sam posted an event in Community Calendar
An After Action Review (AAR) is a facilitated discussion following an event to understand what happened and why. AARs involve key stakeholders involved in the incident and provide insight into how improvements could be made to help deliver safer care for patients. The AAR process emphasises the importance of a facilitated approach with all participants encouraged to work collaboratively to identify possible changes and improvements. AARs provide all participants with an opportunity to reflect and consider opportunities for self-learning. AARs are gathering momentum within healthcare particularly since the approach was identified as one of the national learning response methods within NHS England’s Patient Safety Incident Response Framework (PSIRF) documentation. The workshop will commence by looking at a brief history of AAR across the globe and its recent transition as an approach to help healthcare teams better understand their patient safety incidents. The core part of the day will focus on the four questions involved in conducting an effective AAR and learners will be given the chance to put learning into practice by looking at relevant case studies and scenarios in small groups. The day will conclude with an honest assessment of AARs and consider the challenges and benefits of utilising this team approach in a healthcare setting. This course is aimed at those who wish to lead and conduct AAR reviews plus those who are likely to take part in AAR investigations. The facilitators for this course will continue the journey beyond the course itself to support and enable you to develop your skills in AAR when you return to your organisation. This masterclass will enable you to: Understand history of AARs and why they are gathering momentum in healthcare Appreciate what an AAR is and how it differs from other incident investigation methods Identify when it is appropriate to conduct an AAR Examine what skills effective AAR conductors require Understand the four fundamental questions involved in conducting an AAR Develop your AAR skills via a number of case studies and scenarios Consider how human factors can play a part in the AAR process Examine why AAR can be an effective mechanism for change and improvement Discuss the strengths and weaknesses associated with AARs Evaluate where you consider you can gain the most from undertaking AAR. Register hub members receive a 20% discount. Email info@pslhub.org for the discount code. -
Content Article
Judy Walker describes how an After Action Review following a sporting event ensured significant learning took place and led to a worldwide change in first aid training.- Posted
-
- Patient safety incident
- Organisational learning
- (and 3 more)
-
Event
HSSIB: After Action Review
Sam posted an event in Community Calendar
This is for those in NHS Trusts in England only. This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course is includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. Learning objectives: Define what After Action Review is. Understand the principles of After Action Review. Know the attributes needed to be an After Action Review facilitator. Understand how to conduct an After Action Review. Register- Posted
-
- Investigation
- After action review
-
(and 2 more)
Tagged with:
-
Event
HSSIB: After Action Review
Sam posted an event in Community Calendar
This is for those in NHS Trusts in England only. This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course is includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. Learning objectives: Define what After Action Review is. Understand the principles of After Action Review. Know the attributes needed to be an After Action Review facilitator. Understand how to conduct an After Action Review. Register- Posted
-
- After action review
- Investigation
-
(and 2 more)
Tagged with:
-
Event
HSSIB: After Action Review
Sam posted an event in Community Calendar
This is for those in NHS Trusts in England only. This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course is includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. Learning objectives: Define what After Action Review is. Understand the principles of After Action Review. Know the attributes needed to be an After Action Review facilitator. Understand how to conduct an After Action Review. Register- Posted
-
- Investigation
- After action review
-
(and 2 more)
Tagged with:
-
Event
HSSIB: After Action Review
Sam posted an event in Community Calendar
This is for those in NHS Trusts in England only. This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course is includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. Learning objectives: Define what After Action Review is. Understand the principles of After Action Review. Know the attributes needed to be an After Action Review facilitator. Understand how to conduct an After Action Review. Register- Posted
-
- PSIRF
- After action review
-
(and 2 more)
Tagged with:
-
Content Article
This is a video presentation from the Royal College of Surgeons in Ireland, looking at facilitation skills for after action reviews (AAR) and the wider process.- Posted
-
- After action review
- Safety process
-
(and 1 more)
Tagged with:
-
Content Article
Innovation in the education and training of healthcare staff is required to support complementary approaches to learning from patient safety and everyday events in healthcare. Debriefing is a commonly used learning tool in healthcare education but not in clinical practice, but little is known about how to implement debriefing as an approach to safety learning across a health system. After action review (AAR) is a debriefing approach designed to help groups come to a shared mental model about what happened, why it happened and to identify learning and improvement. This paper describes a digital-based implementation strategy adapted to the Irish healthcare system to promote AAR uptake. The digital strategy aims to assist implementation of national level incident management policies and was collaboratively developed by the RCSI University of Medicine and Health Sciences and the National Quality and Patient Safety Directorate of the Health Service Executive. During the Covid-19 pandemic, a well-established in-person AAR training programme was disrupted and this led to the development of a series of open access videos on AAR facilitation skills (which can be accessed via the link to the paper). These provide: an introduction to the AAR facilitation process a simulation of a facilitated formal AAR techniques for handling challenging situations that may arise in an AAR reflection on the benefits of the AAR process. These have the potential to be used widely to support learning from patient safety and everyday events including excellent care.- Posted
-
- Training
- After action review
- (and 4 more)
-
Content Article
Judy Walker talks about improving team performance through the After Action Review approach and the importance of AAR Conductor training.- Posted
-
- After action review
- Training
-
(and 2 more)
Tagged with:
-
Content Article
In this blog, Judy Walker, an After Action Review (AAR) expert, looks at how effective learning from disasters and incidents can restore hope and trust, offering long-term improvements to systems that have failed. She talks about how public inquiries, although they can seem frustratingly slow, benefit society when the relevant authorities ensure that learning is understood and implemented. She compares this to the impact of AARs, highlighting that people’s trust in the process is linked to their perception of the changes that happen as a result of the AAR. She outlines three steps that NHS providers should take to ensure the AAR process is effective in restoring hope: Highlight to all staff on a regular basis, the benefits that are being delivered due to AARs Ensure patients and family members are provided with specific information about how AARs prevent future harms Support the people who lead AARs to do so skilfully, so that quality is assured and staff can trust in the safety and value of the process.- Posted
-
- After action review
- Organisational learning
- (and 4 more)
-
Content Article
This paper, published in Applied Ergonomics, looks at how those in healthcare might select which technique to use to predict error. The author concludes: "there is a lack of practical experiences described in the literature to conclusively define a technique for selection and a need for a dedicated research in this area to make it accessible for healthcare and other novice users".- Posted
-
- Root cause anaylsis
- Staff support
-
(and 1 more)
Tagged with:
-
Content Article
In this blog, Judy Walker, Senior Business Consultant at iTS Leadership, describes an After Action Review (AAR) that took place at a large London hospital following the first wave of Covid-19. As part of the AAR, Emergency Department porter Aaron described his experience of the first Covid 19 surge—wheeling large numbers of patients who had died through an empty hospital. Judy describes the value of staff listening to different perspectives as a way to reflect on their own experiences and understand the impact events have on different individuals. She highlights the importance of listening to the process of learning for individuals and teams.- Posted
-
- Staff safety
- Pandemic
- (and 5 more)
-
Content Article
Work to prepare for transition to working within the Patient Safety Incident Response Framework (PSIRF) in the Autumn of 2023 is well underway by healthcare providers across England. Written for all those involved in implementing PSIRF, this article describes some of the reasons behind the challenges being faced and suggests three principles to help navigate through this complex process and offers practical ideas to help.- Posted
- 1 comment
-
1
-
- PSIRF
- Organisational culture
- (and 4 more)
-
Content Article
NHS England’s Patient Safety Team will be launching the new Patient Safety Incident Response Framework (PSIRF) in the Spring of 2022, and one of the tools it will recommend to enhance learning from events is After Action Review (AAR). It is likely that each healthcare provider will define its own 'playing field' for AAR as the PSIRF is integrated in daily practice in the months and years ahead, yet this can extend far wider than many assume. In the 12 years since I was trained as an AAR Conductor, I have grown to appreciate its adaptability as well as the many benefits it delivers. The examples of real AARs described here are designed to illustrate some of the many applications. As you will see, these AARs have created opportunities for learning at three levels, all of which contribute to the delivery of safe and effective patient care: the individual, the team and the organisation.- Posted
-
2
-
- Patient safety strategy
- Training
- (and 4 more)
-
Content Article
Debriefs (or After Action Reviews) are increasingly used in training and work environments as a means of learning from experience. Tannenbaum and Cerasoli assessed the efficacy of debriefs with a quantitative review and found organisations can improve individual and team performance by approximately 20% to 25% by using properly conducted debriefs.- Posted
-
- After action review
- Research
-
(and 2 more)
Tagged with:
-
Content Article
Judy Walker, iTS Leadership, presented at the recent Patient Safety Management Network drop-in session on After Action Reviews. View the presentation below.- Posted
-
- After action review
- Organisational learning
- (and 2 more)
-
Content Article
Julie Avery and Brian Edwards, Chartered Institute of Ergonomics and Human Factors, presented at the recent Human Error Forum. They share their presentation slides on human performance and organisational learning and how to integrate human performance into existing systems.- Posted
-
- Human error
- Human factors
- (and 3 more)
-
Content Article
An example of how After Action Reviews are used by the US Army. An After Action Review (AAR) is a professional discussion of a training event that enables Soldiers/units to discover for themselves what happened and develop a strategy for improving performance. Facilitators provide an overview of the event plan (what was supposed to happen) and facilitate a discussion of what actually happened during execution. -
Content Article
Organisational learning requires that teams continuously assess their performance to identify and learn from successes and failures. The After Action Review (AAR) is a simple but powerful tool to help you do this. Conducting an AAR at the end of a project, program or event can help you and your team learn from your efforts. Furthermore, sharing the results from your AAR can help future teams learn your successful strategies and avoid pitfalls you have worked to overcome. -
Content Article
External clinical harm reviews aim to give assurance to patients, patient groups, commissioners and the public as to whether any patients have been harmed as a result of an incident, as well as to avoid future harm to patients. This handbook by Dr Henrietta Hughes, NHS Medical Director for London North, Central and East, outlines an approach to conducting clinical external harm reviews. It identifies the factors which make external clinical harm panels successful and provides example agendas and terms of reference for the process.- Posted
-
- After action review
- Clinical governance
- (and 4 more)