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?