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This short 2 minute video testimonial is from a Doctor of Emergency Medicine reflecting on how she has seen the significant benefits of Atrainability Human Factors training

 

 

Atrainability Blog

Here we share some thoughts, insights and ideas related to Human Factors Training

Human Factors and Patient Safety Updates





PATIENT SAFETY TEAM OF THE YEAR

The winners of the HSJ 2018 Patient Safety Awards have been revealed. Well done to everyone who was nominated, commended or won! In particular, we'd like to congratulate the University Hospitals Coventry and Warwickshire Trust Patient safety and risk team. Their team have been awarded the Patient Safety Team of the Year. 


"Integrating Human Factors principles into our safety investigations has been a key part of the changes we have made. An understanding of these concepts is key to learning and improving as an organisation when things go wrong. We started our Human Factors journey two years ago with Atrainability and their Train the Trainers course, and this gave us the knowledge and confidence to develop a systems based investigation process that moves away from blame, towards learning and ensures that the patient is at the heart of what we do." 

- Stephen Tipper, Human Factors Programme Manager

Since instituting a raft of measures over the last year the incident reporting rate at the organisation has increased from 31 to 44 incidents per thousand bed days – in the top 25 per cent nationally. There have also been improvements in staff survey responses on feeling secure when raising concerns.

We of course can not take credit for their achievement but we are proud to have played a small part of their wider plan to make sustainable changes to patient safety with the 5 day Train the Trainer sessions we ran with them two years ago.

Read more about their changes and award here.


TRAINING WITH THE TEAM AT UHNM

Last week we ran 2x two-day Human Factors Awareness workshops for adult and children intensive care teams at UHNM. The courses were presented by our Founder, Trevor Dale and one of our new team members, Rick Craft.

During one of the two-day sessions, our trainers had the pleasure of talking with Emma Biddulph, a Play Specialist who is featured in an article in The Guardian on 70 years of the NHS. Emma told us:

"I came not knowing what to expect, but I found this course really interesting and useful. I plan to start implementing human factors learning asap in my daily practice."

Emma Biddulph, a Play Specialist
We're happy to report that 100% of the staff said they would 'Reccomend this training to a Colleague' and 100% also told us that as a result of the training it was likely or very likely that they would be able to apply the learning to their practice. Enquire about Human Factors Awareness Course

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A systems thinking approach to error

Attending the Clinical Human Factors Group Open Seminar this year was a great pleasure in many respects, interacting with old friends and new. Learning about updates and gaps in my knowledge in all aspects of Human Factors, was so very valuable.

It was evident from the conference that systems thinking is the way forward and the overriding theme of the day was about looking at the bigger picture whilst ensuring we don't lose sight of the individual in the process, especially the patient. We lose sight of the individual at our peril, but more than that, the patient's peril.

When organisations want to identify specific areas to improve or show evidence that they have indeed achieved improvements, data is crucial. But data so often can mask the fact that we are of course dealing with real people.

Whilst 'live tweeting' at the conference about this very subject, a fellow tweeter commented:

And how very true that is; you need both the data combined with the human story to understand why change is needed, why something has gone wrong or particularly well and also to convince others to become advocates, sharing the learning and helping to implement what is required. 


We completely support the idea of systems thinking. One of the talks that I listened to with interest was focussed on Root Cause Analysis. They talked about one particular study and what they found was the Root Cause often came back as: 


                                                                                   "Process Not Followed". 


Now, that sounds like an easy answer, but firstly, that doesn't give much to work with. That's almost as bad as pointing your finger at someone and saying, "That person didn't do it right." More details are needed to understand what is going on.

Taking a systems approach to the 'Root Cause' would take into account the bigger picture and begin to investigate WHY it wasn't followed. 


Is it a training issue for the individual? 

Is there something wrong with the process which means it's very difficult for front line teams to do their job and adhere to the process?

Or, could it be the person is in the wrong job? 

Perhaps it's 'the process' and not the person that is the real Root Cause and it needs revisiting. 

It certainly seems to be the case with a number of Surgical Safety Checklists, where it looks like the checklist itself is not fit for purpose. 

We are currently working with an NHS Trust where the checklist is not fit for purpose. Investigating, observing and promoting open conversations with front line individuals is a good start for any organisation that wants to understand what they can do to make improvements. 

Overall there was a strong feeling of optimism at the Clinical Human Factors Group Seminar. There are, without a doubt, more people taking an interest in Human Factors in healthcare and there is also some truly excellent and insightful work on developing solutions to changing the Culture on this…even if, at the same time, it's apparent there are still some pockets of resistance.

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CQC - From 'Requires Improvement' to 'Outstanding'

Claire Hughes, Critical Care Matron

If you've been following us for a while you'll often see us mentioning in our blog that one of the many ways you can recognise a good team is the fact that team members will take the time to tell their colleagues when they've done something well.

On this subject then, we feel it's important to walk the talk and congratulate one of the Trusts we've been working with for a while, The Critical Care team at Royal Stoke University Hospital.

Following their previous Care Quality Commission inspection, the leadership team, with the support of the trust made the decision to embark on a transformation programme to address the issues that had been highlighted.

As a result the CQC rating of their Intensive/Critical Care unit has been changed from 'Requires Improvement' to 'Outstanding'. Read their report here


Implementing Human Factors training combined with support for a full transformation programme has helped make this possible.


Claire Hughes, Critical Care Matron at Royal Stoke writes:


"The Critical Care Team at University Hospital of North Midlands has invested greatly in Human Factors training with the aim to have 50% of all staff trained in this topic.

Our unit has undergone a Transformation Program to bridge identified gaps between the General Provision for Intensive Care (GPIC's) guidance against a former baseline position. Specific work was required to address incidents both local and intra hospital.

Trevor Dale was able to provide an excellent foundation training schedule to address the issue and instigate 'Human Factors' as a challenge and change culture for our unit.Staff who have attended the training course are fully complimentary of the skills attributes gained from the overall experience and scenario based learning.

It is already evident that Human Factors training is positively changing everyday practices and culture amongst the many staff on our very busy critical care unit.

A recent Major Incident highlighted how significant communication and human factors was, to ensure patient safety in this complex situation. For this, we thank you Trevor and the team"


This Critical Care unit is a great example of how having the support of the leadership team and Trust when it comes to implementing positive changes through training can make a difference.


By approaching learning as an ongoing journey of development and not a tick box exercise you can make improvements that are sustainable. So congratulations to all the hard work the team has put in towards making it happen.

It's been an absolute pleasure to be part of their improvements and we are looking forward to our continuing to work with them.



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A Situational Violation



Picture yourself in this situation; you're an Anaesthetist who has been called to attend to a patient who needs an emergency C-section. There's a small window to act fast and save the baby, but you notice that the patient isn't wearing an identity wristband. Would you anaesthetise?



Before we go any further, consider this similar situation before making a decision on what your course of action would be. Again, a real-life story that we've been made aware of recently. 

A small boy and his mother are rushed into a busy A&E department at an NHS Trust, the boy having been mauled by a dog. The child is quickly referred to the Trauma Team and there is no doubt that they have the right child; he's covered in blood, bite marks, screaming and the mother is upset as you'd expect. They do what needs to be done, they do their jobs, clean wounds and patch him up. Afterwards, they find out he's got the wrong wristband on. 

The hospital decides to deal with this error with disciplinary action against the Clinicians. 

Take a step back and you can see how a small mistake like this can occur. A busy department, a small boy screaming, arms flailing about…he requires urgent medical attention and it's clear what he needs; but why go straight to disciplinary action, and if not a disciplinary then how should it be dealt with? 

Treating individuals of any specialty, nursing or clinician like responsible professionals is almost guaranteed to have a much better outcome. This incident should have been approached as something to learn from, a discussion point. A team conversation in which this error is highlighted and shared. An opportunity for staff to explore all the circumstances which led to the name check being missed, to think about the likelihood that this could happen again, and then if necessary, think about steps that can reasonably be taken to avoid a repetition of this error. 

Using a risk matrix can help differentiate between low frequency events with very serious untoward outcomes and those with much less serious outcomes. And of course, the risk of not taking action must also be assessed to give a balanced perspective.


Let's think again about the mother who needed an emergency C-section. 

On this occasion, the Anaesthetist refused to anaesthetise the patient because of the missing wristband, which lead to a ten minute delay while they got a wristband on her. The result of this, was that the precious opportunity to get the baby out safe was missed. The child is now permanently brain damaged. 

The easy thing to do is blame the Anaesthetist. He or she could have acted differently, taken a risk, broken a rule to act fast and then justified his/her actions later. Or perhaps the finger of blame points at the nurse or doctor who was responsible for making sure the patient had a wristband on? 


Of course, there's other elements to muddy the waters. 

What does this individual normally do? Flout rules or routinely demonstrate good practice? Do they have previous history which led to this particular decision? Were they previously involved in, or even just exposed, to a patient misidentification that resulted in serious harm? 

Patient misidentification is known to contribute to errors and is a cause of patient safety incidents; including operating on the wrong patient, or performing the wrong procedure, or performing surgery / an intervention on the wrong body part (e.g., right vs. left knee replacement operation). 


So what's the answer here? 

It's a tragic story and an upsetting, ongoing experience for all involved. We feel however that it highlights how easy it is for leaders to unintentionally get it wrong and in doing so, stopping professionals from getting it right. 

One major factor in high risk decision making has to be whether your front line team feel safe and supported. Now, what that means to us is that a management system needs to be set up and run in such a way that makes front line staff feel safe. This must be borne out in reality, as opposed to being implied and then not acted on when the time comes;


"Well of course you're safe with us, we operate a no-blame culture"


Saying it doesn't make it true. 


Did the Anaesthesist feel safe? 

If frontline staff feel they have to protect themselves first from disciplinary action or being struck off then that's how hospitals end up with staff who will refuse to do something that in hindsight would have been the "sensible" action. The sense of covering one's own back is a normal human reaction to a perceived threat and it is a clear signal that all is not well with the system. 

If individuals and teams feel safe and supported it will reduce stress and they will feel enabled and empowered to make better decisions. This not only means better care and outcomes for patients, but also builds trust and team morale. 


Join us for the our next Masterclass in London.

Atrainability are now working alongside Quality Improvement Clinic to offer a one-day Masterclass which combines Human Factors and QI Science which will be running on 25 June 2018 in London. Read more about the masterclass here or Register for the event here.

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HFE in Healthcare, Investigation and Education


We at Atrainability are proud to have been invited to sponsor the

Clinical Human Factors Group's upcoming Aberdeen Open Seminar on 23 May.


"We are honored to be supporting this event and pleased to be able to contribute towards the ongoing mission of the Clinical Human Factors Group" - Trevor Dale, Managing Director, Trevor is also planning to attend the event and he hopes to see you there.


Please find further details below:

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CHFG's next Open Seminar will take place in Aberdeen on the 23rd May 2018.


The Keynote speakers are:


• Keith Conradi, who will provide an update on the developing work of the Healthcare Safety Investigation Branch (HSIB)

• Dr Paul Bowie from NHS Education for Scotland and Craig McIlhenny at NHS Forth Valley Scotland, talking about the new national multi-agency initiative on Human Factors in NHS Scotland.

Breakout session topics include:


Dr Karthryn Mearns - Safety culture - we can measure it, but can we manage it?

• Manoj Kumar - Safety reviews: bridging the gap between work as imagined and work as done

• Professor George Youngson - The impact of bullying and discrimination

• Dr Helen Vosper - Human Factors as a strategy for improving Medication Safety

• Dr Alastair Ross - The Functional Resource Analysis Method and how to develop a model of everyday work

• Professor Ron Mcleod - Bowtie analysis as an approach to the assessment of the risk in healthcare

• Dr John Rutherford and Dr David Macnair - Good practice in running Human Factors training in a district general hospital

• Dr Shelly Jeffcott - Pushing back on "the way we do things around here": What holds us back from integrating HF/E


This one day event will focus on Human Factors in healthcare and applications in investigation, clinical practice and education.


Register for the event here & View full programme here.


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Unintended Consequences

(Revised: 15.2.18)

In the wake of the tragic death of Jack Adcock and the conviction and subsequent striking off of Dr Hadiza Bawa-Garba, we need to work together to rebuild the damage done to the safety culture. How? Revenge and blame feel great don't they? But neither of these options offers a solution to stop repeated errors. It is easier to point the finger at an individual, rather than a flawed system.*

Martin Bromiley is a shining example in seeking no retribution in the aftermath of the death of his wife, Elaine. Instead, he has made it his life's mission to educate others. 


It should be highlighted is that the mitigated circumstances which often lead to a tragedy, are sadly not unique.

The abnormal, such as multi-tasking, staff shortages, no handovers, hierarchy barriers etc…eventually becomes normal practice. We want to help professionals in all status's and across all aspects of health and social care feel safe and encouraged to report and aid learning from the most basic of human conditions, fallibility. 

Time and time again you've probably been told that near misses (near hits?) and incidents are the richest source of learning. Yet we still find that these often go unnoticed in all fields, sometimes because they don't get reported. Or, as mentioned by some professionals we've spoken with recently; it's because "human factors" is stated as the cause of the error yet it's not adequately analysed, or learned from and the true underlying causes remain. Perhaps this is a side effect of the abnormal becoming normal? 


I appreciate that too much has been made of aviation as a model. 

But one thing I would argue is indisputable is that the way the culture changed was by embedding human factors ergonomics principles in every single thing, from training through to all processes. My own son, flying now for a major international airline simply says "it's just the way we do it!" – but it took time to get to that stage. 

The term Human Factors is certainly more heard of and understood in healthcare than it was when we started fifteen years ago; but a one-off Human Factors course as part of a knee-jerk reaction or tick box exercise will not make sustainable changes.


It's one thing to say you know about Human Factors – but what actions are you taking? 

We're currently delivering long term training solutions with coaching and ongoing support to a number of NHS and private providers. Train the Champion and Train the Trainer as well as foundation awareness are helping to kick start that embedding process. It is terrific to see how general awareness is growing! 


But it's not all about error. 

It's important that teams understand why things "go right" too and how to repeat that. One organisation we've just tendered for are rated 'Good' across the board by the CQC, but they want to achieve 'Outstanding'. That's the way to go.

Please get in touch and let's see how we can help your teams. 


PS. *The British Medical Association has just launched an online space allowing doctors to report their experiences and examples of how the system is preventing them from providing safe care. https://r1.dotmailer-surveys.com/00jvxef-a92tly1f


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An apology regarding the earlier version of this blog piece sent out via e-mail on 15 Feb 2018:

We at Atrainability regret that we have passed on some mis-information in the earlier version of this blog piece, distrbuted via our e-newsletter on 15 Feb 2018.

Prof Terence Stephenson, Chair of the GMC made a statement on 2 Feb 2018 that in fact the e-portfolio reflective statement was NOT used as evidence against Dr Bawa-Garba. The GMC have clarified that the details reported in this case were not accurate.

Thank you to those of you who took the time to inform us about our error. We have amended the above post and resent out a revised copy of the e-newsletter to reflect this. Despite this unfortunate error, we believe that the potential damage to the reporting culture is still tangible and valid based on our conversations with a number of Clinicians.

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A ZERO fatality year...

Once again we've heard comments that aviation and healthcare are radically different, the point being of course, that healthcare can't possibly transfer learning from an industry such as aviation. Well of course our industries are different, but it's not as simple as some people think.

We've heard this so many times. 

"Pilots would not get airborne with a plane that wasn't working properly, where as Doctors and Nurses are dealing with people who've had something go wrong" 

This misses the point. 

Most people don't realise that if something goes wrong in an airplane, rarely do you see it coming and the chances are we're already airborne. 

Aviation in the 21st century is incredibly safe, so much so that there is talk of a zero fatality year worldwide due to accidents, leaving aside deliberate acts. 

Extrapolating this it suggests that aviation is, as is often claimed, 99% boredom 1% sheer terror. Not strictly accurate, but mostly things do not go wrong, but what flight crew have to maintain is a wary eye for potential problems.If they occur…

The enemy here is complacency. 

Flight crew, like healthcare teams, have to be like the proverbial coiled spring, ready to react, safely and sensibly in times of extreme stress and with limited options. 

In a nutshell, where learning from aviation can be beneficial and transferrable to healthcare is via our techniques and methods for understanding human behaviour. Being able to be proactive rather reactive, be situationally aware as well as self-aware, understand how to communicate effectively to avoid misunderstanding. 

These skills when mastered, can create leaders and teams who can make better judgement calls, minimise risk and maximise safety. Knowing what we do about the effects of the amygdala and fight, flight and freeze, it is the ability to control your actions under extreme stress that we have to practice. 

Preparedness is crucial. 

Flight crew are trained to consider what could realistically ruin their, and you the passengers, day. One of the aviation techniques is to use periods of low activity, not to simply chat and pass the time of day, but to discuss with your colleagues and your team what they might consider to be a potential problem. When flying how would we handle a depressurisation or a hydraulic system failure. In healthcare something akin to a cardiac arrest or pranging a major blood vessel, or an unanticipated allergic reaction for instance. 

Alternatively a challenging aspect could be when you know you're going to be working with a difficult colleague, so you could discuss in advance how you will try to change the trajectory of incivility into a harmonious team outcome. 

Atrainability are able to provide tailored Human Factors support for teams that are in need of advice, support or development.

Further reading...

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Improvement Science for Better Outcomes

Atrainability have teamed up with The Quality Improvement Clinic and QIC Learn to create a one-day masterclass which will show you how Human Factors and Improvement Science can help you deliver better outcomes.

Small changes can effect big changes and we can equip you with the knowledge and confidence to take new ideas back to your setting.

What will I gain?

After taking part in this masterclass delegates will be able to:

• Be inspired to use human factors and improvement science to deliver better outcomes for their patient e.g. during transitions of care

• Understand Threat and Error Management - an essential concept in learning from error and success

• Understand and accept the causes of mistakes -how to maintain confidence in the high pressure workplace

• Know the early warning signs that things are not as they should be and what to do about them

• Understand and adopt effective communication -ensuring mutual understanding

This 1 day masterclass has been designed to give you an appreciation of Human Factors in the workplace and how it can help you deliver better care.

Through attending this course, you are becoming a change agent, leading the way to help make your patients and your ward safer with Human Factors.

We look forward to you joining us on Friday 23 March 2018.

​BOOKING NOW:

Human Factors Principles + Improvement Science = Better Outcomes


When: Friday 23 March 2018
Where: De Vere West One Conference Centre, London

JOIN US:
Click to find out more OR
Click to book online

. **Special Offers** 15% Group booking Discount or 10% Card Payment Discount
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Debriefing - The Holy Grail

Debriefing or feedback is a vital part of ensuring teams communicate effectively and learn from experiences. How good are we at giving and accepting praise and positive feedback?

An insight I've gained from working with and observing teams is how surprised individuals can be when given positive feedback. Also sometimes they have real difficulty accepting it and view it as patronising. But feedback is a gift and let's be honest we don't do it well. Most of us are swift to blame and slow to praise.

Perhaps it's that quintessential Britishness which hinders us thanking or complimenting a colleague's contribution or skill? We are a very multicultural society now and what richness that brings, so perhaps we can move forward.

Being praised for good performance not only raises morale but improves trust and performance within the team and beyond. It can benefit sickness rates and staff retention as it has in some of our clients.

I recently had the privilege of watching a series of Maternity deliveries by C-section. After introductions during one of the safety huddle at 8am, I explained I was hoping to observe and help them recognise what they've done well – and so it proved to be.

The team were not anticipating any particular problems, and although the first mother had a history of previous C-section deliveries, a scan had been conducted to check the position of the placenta.

Unfortunately, when accessing the uterus they encountered Placenta Previa, and along with the accompanying significant blood loss it was discovered that the baby had inhaled some of the fluid. Rather than a healthy cry, the baby omitted a half-choking squawk and instantly the body language of the team changed and the call was made for the paediatricians to attend urgently.

To cut a long story short, I can report that all was handled extremely well and the baby was quickly whisked off and the outcome was a healthy mother and child.

Afterwards I was asked by the team for feedback. After going into some non-clinical detail on how they'd handled a tricky situation really well I then encouraged them to provide some positive feedback to each other. It did not come naturally, but eventually the Registrar agreed that yes it did go very well. When asked if she could tell me why, she looked stunned and after some thought replied;

"The Scrub Nurse did a great job and I had everything in my hand before I barely asked for it."

With some gentle reassurance, The Registrar relayed her positive feedback to the Scrub Nurse directly.

After being told what a great job she'd done she beamed and said,

"Firstly I'm a midwife, not a scrub nurse. I am only doing this because the scrub nurse called in sick today, it's not my normal job."

I said "Well you've just had some great feedback!" She then added "When they pranged the placenta my heart sank and I thought we were going to have real problems but what held me together was how calm the two surgeons remained as they handled the situation successfully."

Soon, the rest of the team started opening up about their own worries and self-criticisms during the procedure, all which were met with empathy as well as positive and constructive feedback from their colleagues.

The senior midwife had been acting as team leader and in a circulating capacity. She thought she had left it too long before comforting the mother and father. I commented that it did seem like a long time, but the parents had looked relaxed and unconcerned. However the only people who could comment were the parents themselves. How about go and ask them? They were in fact fine.

Everyone now professed that they felt so much happier and confident. They all had a much better team understanding. Everyone was smiling and the atmosphere was positively buoyant.

So what's the moral of this story? You don't really need a trainer to tell you what you've done well, but you might need some help to get your team to a place where positive and constructive feedback become the norm.

We'd be delighted to help you.

Atrainability offer both in-house and Open Course training and coaching solutions. We'd be happy to have an informal chat (in confidence of course) to discuss your current challenges. Please get in touch and one of our team will get back to you

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A renewed focus on NatSSIPs

NatSSIPs - National Safety Standards for Invasive Procedures 


Many of our prospective clients often tell us that they are working successfully towards a safer culture, and yet never-events and avoidable harm do not appear to be diminishing on a National basis.* 

Let's look at NatSSIPs and LocSSIPs on which there is a renewed focus at this time. Otherwise known as the Five Steps to Safer Surgery. 

LocSSIPs is a topic that we have masses of experience in, helping Trusts develop their own best practice in briefing, checklist and debriefing . We are privileged to witness many excellent demonstrations using Natsipps techniques but sadly, we occasionally meet individuals who think they don't need such aids to safety. 

Very recently I was disappointed to witness a Clinician quite deliberately reading news reports on his Smartphone while a Safer Surgery Checklist was being read. Sadly his clinical colleague said nothing. Rest assured that the situation was rectified at the time. However this is still not unique, though happily rare. 

We have a responsibility to ensure the importance of NatSSIPs and the reasons behind its introduction are understood. In our view (and others) the use of checklists and safety techniques is not a personal option, but a mandate and a necessary core function of professional surgical performance. 

NatSSIPs is built around the aviation based concept of threat and error management. This came out of the original NASA funded research at the University of Texas under the late professor Bob Helmreich. 


Threat and Error Management is three steps: 

•AVOID – in an ideal world you would avoid everything that could possibly go wrong

TRAP - But of course you can't avoid everything in the real World. What you haven't been able to avoid you would wish to trap, in order to minimise any errors resulting in potential harm. 

•MITIGATE (read definition)- Finally, one needs to reduce the effects if harmful but to stretch the meaning of 'Mitigate' – to learn from failure and of course success. 


How does this work in practice? 

In healthcare, as in aviation, the 'AVOID' phase is accomplished by having a briefing (Handover or Safety Huddle) normally performed at the start of a working shift or day. This is where the team get together, share plans for what should happen, build situation awareness (Plan A) across the whole team and prepare themselves for what they hope won't happen (Plan B, plan C etc). 

'TRAP' - The 3 steps of the WHO Safer Surgery Checklist fulfil this role.The checklist serves as a memory aid to ensure all necessary safety issues have in fact been completed. Note – it is a Checklist - not a TICK LIST. It is completion of the actual CHECK that is crucial and not the ticking of a box! 

Finally, 'MITIGATION'. Debriefing sits here as a tool for learning not blame. In the case of a successful outcome debriefing is the opportunity to discuss what went well, why it went well and how we will try to ensure it goes well tomorrow and thereafter. 

In the event that it has not gone well, rather than resorting to blame and finger pointing; this step serves to investigate why and how something went awry. How and why well-intentioned, well-trained people have perhaps made an error, with a view to genuinely learning lessons and moving forward effectively for the whole team and ultimately the organisation and the profession. 

Duty of Candour sits here too and is of course a legal, professional and a compassionate necessity. 

After all, quite apart from the safety aspect, who gains the most respect? Someone who accepts and owns up to their own fallibility or someone who seeks to hide it? 

Atrainability would be delighted to assist you in implementing LocSSIPs for your teams, please get in touch to arrange an informal phone chat at your convenience. 


*Source: Never events data, click here

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