Patient Safety Courses

How we respond to incidents is crucial in terms of managing the situation, sensitivity, learning lessons, and adding to prevention strategies. This comprehensive course examines best practices in incident response and how our responses can develop, utilising role play and case studies for immersive learning.

Who is it for?

This course is ideal for those leading patient safety incident investigations with a focus on practical skills such as evidence gathering, interviewing, and reporting.

Learning outcomes:

By the end of this programme, learners will be able to:

• Articulate a clear understanding of the principles of Patient Safety Incident Investigation (PSII)
• Apply the PSII principles to investigations
• Identify and obtain key evidence including documentary evidence and statements
• Use effective interview techniques (structured, semi-structured, cognitive)
• Undertake interviews with staff, patients, and families in an effective and sensitive manner
• Evaluate organisational factors and culture
• Analyse and interpret the evidence obtained and draw conclusions about causal and contributory factors and systems
• Write effective recommendations to address the key issues in the investigation
• Consolidate and report the findings in a high-quality investigation report

Learning content:

• Safety incident investigation – analysing the situation and decision-making protocols explain why the decision to investigate is made and consider other options
• Roles and responsibilities for investigations
• Planning an investigation in line with national requirements
• Principles and agreement of robust and meaningful terms of reference and maintaining focus
• Collection of evidence for an investigation systems approach
• Evaluation, review, and weighting of evidence
• Preparing an interview and establishing rapport
• Conducting an investigative interview using a structured approach model
• Identifying additional support and expertise
• Writing an investigation report with clear actionable recommendations and conclusions
• Supporting patients and staff following an incident
• Responding to concerns of relatives, patients and witnesses
• Human factors and healthcare incidents

Who is it for?

This course is best suited for individuals new to investigations or those looking to refine their foundational skills, particularly around PSIRF and stakeholder engagement.

Learning content:

• Introduction to PSIRF
• Why should we do this? Exploring personal objectives and outcomes
• Complex system thinking and human factors
• Duty of candour and just culture
• How to review case records and other key documents
• Analysis skills
• Support processes and stakeholder involvement
• Interviewing and observational skills
• Appropriate questioning including applying Systems Engineering Initiative for Patient Safety (SEIP) model
• Writing a report with clear strategies to avoid further harm
• Scenario exercises

The priority of the patient incident response is to address serious threat of injury, discomfort, or threat to life and identify any learning that can be generalised to prevent reoccurrence. It must also support any affected person through the process with transparency and candour.

Patient Safety Investigation is a complex task that requires skill, knowledge, time, and resource.

Who is it for?

This course is designed for strategic leaders overseeing incident responses, with an emphasis on systems thinking and proportionate action.

Learning outcomes:

By the end of this programme, learners will be able to:

• Understand the systems approach to Patient Safety Incidents examination/investigation (PSII)
• Outline the aim of PSII in supporting learning improvement and prevention of recurrence by reviewing the Systems Processes and Practice
• Apply criteria for appropriate examination and proportionate action
• Respond to a patient safety incident - requiring Patient Safety Incident Investigation (PSII) based on the local strategic plan
• Manage risk in the decision-making process for investigation of highest risks and the greatest potential for improvement
• Support any individual or team involved in the incident or investigation

Learning content:

• Understanding will be tested through pre-course reading and in-course exploration of the Patient Safety Incident Response Framework (PSIRF)
• Decision-making in response to a patient safety incident
• Utilising the patient safety response plan tool to complete situational analysis
• Review, methods appropriate alternatives to investigation
• Involving patients, families, and carers in incident response, including duty of candour
• Developing safety actions and safety recommendations

Leading and managing services within large complex systems like healthcare is challenging. The problems facing organisations are so complex that they defy simple solutions, and leaders are often trying to navigate many competing and conflicting challenges and relationships when making decisions.

Systems thinking is an approach to problem-solving that views ‘problems’ as part of a wider, dynamic system. It is the process of understanding how things influence one another as part of a whole.

Who is it for?

This course is suitable for managers in the public sector responsible for commercial and policy problem-solving in their organisation. Scientists want to take their research into practical applications.

Learning outcomes:

By the end of this programme, learners will be able to:

• Apply systems thinking to a wide variety of social and technical systems
• Utilise the method of drawing systems diagrams to represent systems and their dynamics
• Apply the formal systems model to practical situations
• Understand feedback loops and their likely impact on system behaviours
• Apply the concepts of complex systems to understand why systems are unpredictable
• Collaborate with others in analysing and improving systems
• Involving patients, families and carers in incident response, including duty of candour
• Developing safety actions and safety recommendations

An understanding of the human factors in patient safety enhances performance and is vital in creating awareness to help prevent accidents. Human factors encompass teamwork, design of tasks, equipment and workspaces, culture, systems, and organisations.

In this introduction, we focus on how we might apply this knowledge in clinical settings.

Who is it for?

All Lead investigators conducting patient safety incident investigations, as well as all Executive, Commissioning, and Service leads. Investigators supporting or overseeing patient safety incident investigations. Any staff who wishes to develop a basic knowledge and awareness of human factors.

Learning outcomes:

By the end of this programme, learners will be able to:

• Gain an appreciation of human factors principles
• Provide a model of human factors to use in the real world
• Provide examples of human factors methods

Learning content:

• Definition of human factors
• Systems Engineering Initiative for Patient Safety (SIEP) model
• Examples & discussion of each SIEPs work element
• Group activity for SIEPs work element using human factors methods
• Self-assessment of learning and development needs

The Care Quality Commission’s ‘Regulation 20: Duty of Candour’ sets out the requirements for health and social care providers across the UK. This regulation intends to ensure that providers are open and transparent with people who use services and other ‘relevant persons’ (people acting lawfully on their behalf) about care and treatment.

The professional duty of candour refers to openness and honesty when things go wrong within health and social care services. It is a professional responsibility to be honest with patients when things go wrong.

Who is it for?

This course was developed for individual healthcare and social care professionals, including doctors, medical practitioners, dentists, registered nurses, allied health professionals, and managers.

Learning outcomes:

By the end of this programme, learners will be able to:

• Define duty of candour
• State function of the duty of candour
• Identify professional regulators involved
• Explain the process of the application of duty of candour
• Understand the “dos and don’ts” of the duty of candour
• Recognise the role of the CQC in the duty of candour

Learning content:

• Introduction to the statutory duty of candour
• CQC Regulation 20: Duty of candour
• Duty to be honest when things go wrong
• Encouraging a learning culture by reporting errors
• Professional guidance for health and social care workers
• The organisational duty of candour

Just Culture allows healthcare professionals to feel safe to report errors and “near misses” openly by enabling a progressive culture of safety. Participants will learn how to apply the just culture algorithm, to reinforce principles and create a culture of learning, that sustainably reduces risk and improves patient safety. Our course focuses on individual behaviours and creating a learning culture for investigators and operational leaders.

Who is it for?

All Lead investigators conducting patient safety incident investigations, as well as all Executive, Commissioning, and Service leads. Investigators supporting or overseeing patient safety incident investigations.

Learning outcomes:

By the end of this programme, learners will be able to:

• Explain the impact of accountability and justice in a patient safety learning culture
• Identify the role of an organisation’s mission and values in building a just culture
• Explain and be able to mitigate judgement
• Identify three system strategies to manage risk in patient safety
• Manage five core behaviours affecting risk
• Perform a causal evaluation of an event
• Utilise the just culture algorithm
• Explore how to implement a just culture

Learning content:

• The history of our social trend toward a more punitive, yet unaccountable culture
• The notions of duty, breach, and consequence as applied to “fallible” human beings
• The scientific, legal, and social basis for a more just culture
• The design of the just culture algorithm
• How to become a role model, mentor, and coach to your employees

Who is it for?

Senior leaders (Execs, Non-Executive Director and Senior Managers) as well as their line managers. This course focuses on organisational strategies, stakeholder engagement, leadership theories, and embedding a progressive safety culture at a systemic level.

Learning content:

• PSIRF requirements for patient and staff involvement
• Organisational learning culture
• Strategies to improve staff and patient involvement
• Developing an effective communication strategy as part of any patient safety investigation
• Understand how to develop a communication strategy to involve stakeholders in the investigative process
• Developing strategies for disseminating information and learning across the organisation
• Stakeholder analysis and how to navigate difficult conversations with confidence
• Change theories and how to apply them within a system
• System leadership theory and processes required to monitor and manage change
• Strategies within the system which will reduce risk of further harm
• Interviewing techniques to support the investigative process
• Apologies within the context of patient safety investigations