How to run a Lesson Learnt session: key roles &...

How to run a Lesson Learnt session: key roles & responsibilities
Session
introduction &
preparation
(5 minutes)
Case presentation
(10 minutes)
LEAD
FACILITATOR
- Introduce trainee presenter &
facilitator
- Recap session structure &
Chatham House Rule
- Provide contributory factors
form to each sub-group Lead or
share between 2-3 trainees
- Ensure facilitator has a copy of the
PSI proforma to guide discussion
- Complete sections A & B of PSI
proforma
- If group is larger than 10, split into sub-groups*
of max. 10 trainees
- Ask each sub-group to appoint a Lead to
feedback on discussion points below
- Optional: Appoint scribe for group as whole
GROUP / SUB-GROUP*
- Divide into sub-groups as
necessary
TRAINEE PRESENTER
- Provide facilitator with a
presentation appraisal form
(if you wish to be assessed)
- Present anonymised case
Group discussion
in small groups
(25 minutes)
- Complete sections C, D & E of
PSI proforma based on group
consensus
- Remember to contribute to
discussions too!
- Invite group to clarify aspects of case ‘story’
- Using the PSI proforma as a guide, ensure the
discussion covers the following:
1. What was the outcome for the patient?
The trainee? The team?
2. What were the contributory factors?
3. What actions would prevent this from
happening again?
TIPS:
- Ask group(s) to discuss each point in turn
- Involve the presenter in discussions
- Encourage group members to reflect on their
own experiences & share your own
- Don’t allow group to get hung up on which
contributory factors fit under which heading –
they often overlap – choose most appropriate
- Seek clarification on the case
‘story’ as required
- Discuss and feedback on each
point in turn
- Optional: Group scribe notes down
contributory factors to case and
any proposed actions for each
factor
- Provide additional info
regarding case ‘story’ as
required / where possible
- Contribute to discussion
Whole group meet
to Summarise
Lessons Learnt
& Next Steps
20 minutes
- Complete sections E & F of PSI
proforma based on group
consensus
- Encourage agreement on practical
next steps
- Ask presenter what were the Lessons Learnt?
- Ask group what were the Lessons Learnt?
- Agree next steps with group – any actions
they want to take forward?
- Recap ground rules & encourage presenter to
complete HIRs form and reflect in portfolio
- Offer support as necessary
Share your views on Lessons Learnt and any actions to take forward
Feedback &
Evaluation
Included in above
summary
- Check PSI proforma with facilitator
- Ask group what went well and ways to improve
future sessions
- Review PSI proforma (completed by Lead)
- Complete trainee presenter appraisal (if asked)
Feedback on how session went & ways to improve future sessions
Session close
- Close the session and give thanks
- Complete facilitator assessment
- Escalate any concerns as per guidance
- Retrieve presentation appraisal
from facilitator (if requested)
Lessons Learnt Patient Safety Incident (PSI) Proforma
This form should be completed for every Lessons Learnt session by the Trainee Lead in
consultation with the session facilitator. Sections C to F should be completed based on
group consensus. Completed forms should be submitted to the named LL administrator
SECTION A: Session details. Please complete the following details:
Trust
Hospital
SECTION C: What was the incident outcome? Please select one option
Death: Any PSI that directly resulted in the death of one or more persons
Severe: Any PSI that appears to have resulted in permanent harm to one or more persons
Moderate: Any PSI that resulted in a moderate increase in treatment & which caused significant but not
permanent harm, to one or more persons
Low: Any PSI that required extra observation or minor treatment and caused minimal harm
No harm includes • Impact not prevented – Any PSI that ran to completion but no harm occurred to
people • Impact prevented – Any PSI that had the potential to cause harm but was prevented, resulting in
no harm to people
Date of session
SECTION D: Why did it happen?
Number of attendees
(excl. Lead & facilitator)
Following the group discussion, please identify which of the factors listed below contributed to
the incident. Please provide a brief statement to explain each factor identified
Facilitator name & Specialty
Lead name & Grade (FY1 / FY2)
Presenter Grade
Gender
Specialty
SECTION B: What happened? Please provide a brief description of the incident below:
Contributory factor
Patient factors
Patient’s condition (complexity and
seriousness); language & communication;
personality & social factors
Task & Technology factors
Task design & clarity of structure; availability &
use of protocols/ guidelines; availability &
accuracy of test results; decision making aids
Individual staff factors
Knowledge & skills; competence; physical &
mental health
Team factors
Verbal & written communication; supervision &
seeking help; team structure (congruence,
consistency, leadership, etc.)
Work environment factors
Staffing levels & skills mix; workload & shift
patterns; design, availability & maintenance of
equipment; administrative & managerial
support; work environment & physical factors
Organisational & Management factors
Financial resources & constraints;
organisational structure; policy, standards &
goals; safety culture and priorities
Wider institutional context factors
Economic & regulatory context; NHS
Executive; links with external organisations
Details
SECTION E: What can we do to prevent similar incidents from occurring? For each contributing factor identified, please consider what actions for learning and improvement are
recommended. Please note that the actions can be aspirational but try to consider practical next steps. Where the trainee(s) feel able to take forward the recommended actions, their contact
details should be noted to determine progress (if any) at the end of the year (inform the named LL administrator)
Contributory factor
Actions for learning or improvement
(e.g. disseminate relevant guidance; implement new training; work with rota-master to redesign rota)
Person (s) actioning
Name(s) and email contact
SECTION F: What are the Lessons Learnt? Following the group discussion, please summarise at least 3 key learning points. Use direct (anonymised) quotes from trainees wherever possible.
Contributory Factors Form
This form can be provided to all trainees participating in a Lessons Learnt session in order to facilitate discussion and analysis.
1. Why did it happen? Consider which of the factors listed below contributed to the incident. Provide a brief explanation for each. Don’t get too bogged down with which heading it falls under!
2. What can we do to prevent similar incidents from occurring? Actions can be aspirational but try to think of practical next steps.
CONTRIBUTORY FACTOR
Patient factors
Patient’s condition (complexity and
seriousness); language & communication;
personality & social factors
Task & Technology factors
Task design & clarity of structure; availability &
use of protocols/ guidelines; availability &
accuracy of test results; decision making aids
Individual staff factors
Knowledge & skills; competence; physical &
mental health
Team factors
Verbal & written communication; supervision &
seeking help; team structure (congruence,
consistency, leadership, etc.)
Work environment factors
Staffing levels & skills mix; workload & shift
patterns; design, availability & maintenance of
equipment; administrative & managerial
support; work environment & physical factors
Organisational & Management factors
Financial resources & constraints;
organisational structure; policy, standards &
goals; safety culture and priorities
Wider institutional context factors
Economic & regulatory context; NHS
Executive; links with external organisations
1. What were the contributory factors?
2. What actions would address the factor(s) involved?