1. PSIRF
  2. One year of PSIRF: 3rd - 7th February 2025
  3. Learning Responses
  4. What training is available?

What are the PSIRF learning responses

How do we review incidents?

Under the Patient Safety Incident Response Framework, there are a suite of options available to reivew incidents further. Each of these methods use a systems based approach to understand and learn from incidents. The variety of options available to review incidents also supports in allowing incidents to be responded to in a thoughtful and balanced way. 

There are four learning responses available: 

Learning Responses
Swarm Huddle 
Swarm huddles are used to identify learning from patient safety incidents. It brings together staff involved to explore and discuss work-as-done to identify system factors affecting why the incident occurred. It is designed to be done within a few hours of the incident occurring and uses the SEIPS methodology to guide discussions. 
Template:  Swarm Huddle report template - Final.docx [docx] 2MB
After Action Review (AAR)
AARs are a discussion of an incident structured around a four key questions. The outcome of the discussion aims to understand why the ‘actions’ differed from what was expected and what can be learned to make improvements. AARs gather insight from the perspectives of the staff involved and can be used to discuss both positive outcomes as well as incidents. 
It is based around four questions: 
  • What was the expected outcome/expected to happen? 
  • What was the actual outcome/what actually happened? 
  • What was the difference between the expected outcome and the event? 
  • What is the learning?

Template:  AAR report template - Final.docx [docx] 2MB
Round Table Review 
A Round Table Review is a learning response to an incident under the new Patient Safety Incident Response Framework (PSIRF). It helps teams:  
  • Identify learning from multiple patient safety incidents (ie similar types of incidents)
  • Agree, through open discussion, the key contributory factors and system gaps in patient safety incidents for which it is more difficult to collect staff recollections of events either because of the passage of time or staff availability.
  • To explore a safety theme, pathway, or process.
  • To gain insight into ‘work as done’ in a health and social care system.

Template:  Roundtable report template - Final.docx [docx] 2MB
Patient Safety Incident Investigation (PSII)
A PSII offers an in-depth review of a single patient safety incident or cluster of
incidents to understand what happened and how. It is a thorough review to understand the complexity of systems led by an investigator with input from a panel to support identifying learning. 

SEIPS

As part of the learning responses, the framework Safety Engineering Initiative for Patient Safety (SEIPS) can be used to help identify learning and improvement. SEIPS supports us to have a systems based approach by looking at the whole work system to help understand how an incident happened. It looks at six elements in the work system and how those elements influence eachother and therefore the outcome. The six elements in the work system are external environment, organisation, internal environment, tools and technology, tasks and person(s).  

Visual depiction of the SEIPS model

You can watch this short video giving an overview of the Safety Engineering Initiative for Patient Safety (SEIPS) model and making a cup of tea to help thinking with a systems approach.