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Course Summary

Incident Investigation Training; A Systems Based Approach to Patient Safety

Course Overview

We were delighted to read, in the new NHS Patient Safety Strategy (July 2019), that there will be a move away from using the phrase ‘Root Cause Analysis’ to using a ‘systems’-based approach to investigations. Previous participants in our courses will be aware that we have always passionately believed that there is never just one or two ‘causes’ of a patient safety incident and that blaming individuals is a barrier to organisational learning.

The phrase ‘Root Cause Analysis’ has led many organisations and individuals to believe they have to select one or two primary causes and indeed the template that is in general, national usage, currently contains a section encouraging this approach.

To reflect the new direction we have re-designed our Incident Investigation training packages and expanded our methodology to allow even more time to be spent on important issues such as patient involvement, human factors and ergonomics, why things go right, a just culture and the lessons we have learnt from handling legal cases and undertaking investigations ourselves.

As always, our primary focus will be on proportionate and effective learning. We will continue to provide delegates with a ‘systems’-based methodology to investigate incidents from an initial understanding of the legal and factual context, through a detailed analysis of the issues and evidence, to production of the formal report.

The first day will focus on information gathering the collection of systemic evidence: physical, cognitive and organisational data and evidence from patients, families and carers. The next section of the day covers evidence management and critical analytical skills. The emphasis will be on practicality and a process that can be incorporated into the health professional’s working day.

The second day of this interactive training will focus on the skills of statement writing and interviewing and then take delegates through a case study. This section of the course can be tailored to an organisation’s individual needs through the provision of a bespoke case study. Previous training sessions have covered maternity, surgery, mental health, primary care, opthamology, infection control, emergency medicine and dispatch, for example.

We will continue to provide free policy and template reviews for clients as part of our commitment to a holistic approach to patient safety.

Delegates will be provided with an electronic toolkit after the training, containing policy, report, statement and timeline templates to help put the methodology into practice.

As always, our courses will continue to be PowerPoint free!


  • Ensure a solid understanding of each step of the investigation process including:
  • How much information to gather and how to gather it
  • Involving patients, families and carers and embracing the duty of candour
  • How to conduct interviews with staff in a just culture
  • How to analyse the information gathered using timelines
  • Identification of factors requiring change
  • The importance of multi-disciplinary team involvement
  • Focus on good practice
  • Making proportionate and effective recommendations
  • Time management
  • Guidance on precision writing

Day 1

9.30am to 10.00am: Coffee and Registration

10.00am to 10.15am: People’s experiences of incident reporting and investigation are gathered and discussed. Overview of the investigation methodology.

10.15am to 10.45am: Human factors and ergonomics; this session will explore how human factors can influence an investigator’s approach and the importance of objectivity.

10.45am to 11.00am: Gathering information; a report is only as good as the information it is based on. Ensuring that information is gathered that will help investigators draft meaningful recommendations. Investigators in the past have tended to gather information to establish what happened forgetting to also gather information on why it happened; the importance of gathering human factors and ergonomic evidence.

11.00am to 11.15am: Coffee Break

11.15am to 11.30am: Case Study 1

11.30am to 12.30pm: Mapping the information using timelines.

12.30pm to 1.00pm: Lunch

1.00pm to 1.30pm: Critical and analytical thinking.

1.30pm to 2.30pm: Identifying barriers and safeguards; a ‘systems’ approach.

2.30pm to 2.45pm: Tea Break

2.45pm to 3.45pm: Focus on writing excellent recommendations, benchmarking, reasonable/measureable action plans and producing standardised reports. Example report format provided.

3.45pm to 4.00pm Conclusion

Day 2

9.30am to 10.00am: Coffee and Registration

10.00am to 10.15am: Overview of Day One learning and consolidation

10.15am to 11.00am: Witness statement writing; an improved standard of statement writing from staff will quicken the process of information gathering and analysis and make the incident investigation more effective.

11.00am to 11.30am: Coffee Break

11.30am to 12.30: Interview techniques; effective and supportive information gathering in a just culture.

12.30pm to 1.00pm: Lunch

1.00pm to 2.30pm: Case Study 2 (including interview role play)

2.30pm to 3.00pm: Tea Break

3.00pm to 4.00pm Feedback; staff, patient, family and carer involvement.

4.00pm Conclusion