Systems approach to learning from patient safety incidents


2-day systems approach to learning from

patient safety


Duration: Two-day course (onsite or residential)

CPD hours: 12


Target audience:

  • Lead investigators

  • Executives, commissioning and service leads for investigations

  • Investigators supporting or overseeing patient safety incident investigations


Course description:

Training to support the development of core understanding and application of systems-based patient safety incident response throughout the healthcare system - in line with NHS guidance, based upon national and internationally recognised good practice.


This course covers the end to end systems-based patient safety incident response based upon the new NHS PSIRF and includes:

  • purpose of patient safety incident response framework

  • introduction to complex systems, system thinking and human factors

  • just culture

  • duty of candour

  • involving staff in incident response

  • involving patients, families and carers in incident response

  • improvement science and developing system improvement plans

  • general response techniques

  • interviewing and asking questions

  • conducting observations, understanding work as done

  • systems frameworks

  • response types

  • patient safety investigation planning, analysis and report writing

  • commissioning and oversight of an internal investigation

  • a high-level overview of system-based response tools


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