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In group: PSIRF – Patient Safety Incident Response Framework

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  • Sara Barton posted an update in the group PSIRF – Patient Safety Incident Response Framework 3 months ago

    Good morning everyone

    I’m interested in finding out about how organisations are structuring your “learning” as we get deeper into PSIRF. 

    We’ve found it’s relatively simple to map the processes around this i.e. how we screen incident reports, theme them, decided PSII’s etc. Although the approach to incidents have changed this side of the framework isn’t particularly abstract.

    Learning is a bit harder – I’ve experienced lots of rich learning get distilled down to a couple of key points, or a cascade email (yes, there’s some exaggeration here but sadly this does happen). There’s a tendency in the NHS to try and make everything grow from an existing physical structure – but I don’t want to designate a “learning committee” that risks drifting into assurance actions only. 

    I’m looking at how knowledge actually moves through our organisation to try and identify our effective networks which are often informal. Has anyone here consciously built/rebuilt a learning network to reach the harder parts of an organisation? 

    I know that systems will emerge, but if the organisation can help with context and creating better opportunities to learn together I want some great ideas about how to do that, and any great examples will be appreciated!

    • Hi Sara, we are testing a new learning structure that links learning themes/projects with governance more meaningfully in real time. It has involved identifying MDT QI Learning Leads and adding in some support alongside re-structuring some of our governance meetings. It is only being tested in two services at the moment but so far so good. Happy to share if useful. Thanks, Jo

    • You pose some really interesting questions Sara, ones ive been thinking about for some time. All of the Trusts im working with to use AAR effectively are asking how to enable learning to be shared more widely. So I’m working with some people at Eva Applications to develop a digital solution. We are nearly ready to pilot it – so the AAR conductor will enter a few fields in the App prior to the AAR, and once completed the AAR use the App to enter the lessons and actions. They can then generate a report for the participants, family liaison etc and all the inputs across the organisation are visible in a dashboard format. Data can also be interrogated as needed. if you want to chat more, please let me know.

      • Hi Judy, We have built this into our incident management system and use the information to share learning and inform improvements in a range of ways. By having the information in our incident management system we are able to triangulate the learning, actions and other data such as incidents not subject to AAR (we call these rapid learning reviews), mortality reviews, complaints, health and safety and risk etc.

      • This sounds interesting Judy, good to catch up today, I’m conscious we didn’t get chance to discuss what you were working on