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Course Summary

Investigating Incidents: A Practical Guide

Start

Tue, 31 January 2023 - 9:00 am

End

Wed, 1 February 2023 - 4:00 pm

A 2-day Masterclass on the practical skills to investigate patient safety incident investigations in any healthcare setting.

This virtual 2-day training session will focus on the first crucial steps of any incident investigation. The emphasis will be on practicality and a process that can be incorporated into the health professional’s working day, as well as one that can be conducted remotely. Mirroring the new Patient Safety Strategy problems will be identified, along with their contributory factors. All recommendations, reports and action plans will focus on systemic changes, multi-disciplinary working and implementing practical changes.

Delegates will be provided with a suite of templates to use during an investigation as part of our commitment to an holistic approach to patient safety.

Delegates will learn:

• How much information to gather and how to gather it

• The role of human factors and ergonomics in patient safety incidents

• How to involve patients, families and carers

• How to organise evidence using Timelines

• How to critically analyse evidence

• How to conduct interviews with staff members and families

• A guide to precision writing

• Identification of factors requiring change

• Identification of contributory factors

• Identification of broken and missing systems

• Understand the key elements of a good action plan

• Making proportionate and effective recommendations

• Pulling a report together 

Course Timetable – Day 1

9.00am to 09.15am Logon, technical knowhow and introductions

09.15am to 09.30am Overview of the investigation methodology.

09.30am to 9.45am Human factors and ergonomics; this session will explore how human factors can influence an investigator’s approach, the importance of objectivity and tips for achieving neutrality.

9.45am to 10.15am Gathering information; a report is only as good as the information it is based on. Investigators must beyond simply gathering evidence to find out ‘what’ happened – they must find and ‘why’ it happened and remember to gather human factors and ergonomic evidence. This will ensure that Investigators possess enough evidence to make SMART recommendations.

10.15am to 10.30am Coffee Break

10.30am to 11.15am Mapping the information using simple and tabular timelines.

11.15am to 11.45am Critical Analytical Skills – How to identify missing or incomplete evidence

11.45am to 12.00pm Conclusion, Questions and Set up for Module 2

12.00pm to 1.00pm Lunch

1.00pm to 1.15pm Recap on Module 1

1.15pm to 1.45pm Critical Analytical skills – how to prepare for interviews. How to conduct interviews with staff members and families

1.45pm to 2.30pm Identification of problems. The importance of standards and precision writing.

2.30pm to 2.45pm Tea Break

2.45pm to 3.15pm Identifying contributory factors, including human factors, broken and missing systems.

3.15pm to 3.45pm Focus on writing excellent recommendations, benchmarking, reasonable/measurable action plans and producing standardised reports. Example report format provided.

3.45pm to 4.00pm Summary, questions, conclusion and feedback

Course Timetable – Day 2

9.00am to 09.15am Logon, technical knowhow and introductions

09.15am to 10.15am Witness statement case study

10.15am to 10.30am Coffee Break

10.30am to 12.00pm Planning for interview. Question drafting case study

12.00pm to 1.00pm Lunch

1.00pm to 2.30pm Incident Investigation case study from start to finish. Reports will be submitted to and marked by the trainers.

2.30pm to 2.45pm Tea Break

2.45pm to 3.15pm Case study continued.

3.15pm to 3.45pm Delegates receive feedback on their incident investigation reports.

3.45pm to 4.00pm Summary, questions, conclusion and feedback