Responsive Training in Learning from Adverse Events is a Success

By James Titcombe, Course Director, Learning from Adverse Events

Supporting staff and learning when things go wrong

The way in which NHS organisations respond and learn following adverse events has repeatedly been highlighted as a cause for concern.  In 2018, the Royal College of Obstetricians and Gynaecologists’ Each Baby Counts report highlighted significant variability in local maternity investigations, the lack of family involvement and the tendency to blame individuals rather than fully seeking to understand and address systemic issues.

The Better Births report (2016) called for a ‘national standardised investigation process when things go wrong’ and highlighted the lack of national training as a concern.

Although many organisations have worked to improve how they respond to adverse events, there still remains a need to provide better training and support in this area. Just last week, the Care Quality Commission (CQC) published a briefing document about progress maternity safety that again highlighted ‘…a lack of investigation and learning when things go wrong’ as an issue.

Baby Lifeline Training is passionate about supporting maternity teams with high-quality, multi-professional training; working with our expert advisory panel, we have developed a new, 2-day training course aimed at supporting maternity staff in how to respond, investigate, and truly learn when things go wrong.

Learn from adverse events – training and guidance

Our new course has been designed in collaboration with experts from Cranfield University, the Healthcare Safety Investigation Branch (HSIB), NHS Improvement (NHSI) and NHS Resolution (NHSR) and is aimed at all members of the maternity team including midwives, obstetricians, risk managers, maternity safety champions, bereavement support staff and all staff involved in quality/safety improvement.

Using a combination of formal talks, workshops, and interactive discussions the course covers the following topics:

  • An overview of the national guidance including reporting and notifications requirements.
  • Practical training on how to support staff following an adverse event, including ‘just culture’ principles and decision-making tools.
  • How to sensitively and compassionately engage with families throughout investigation processes, sharing the best practice model developed by HSIB.
  • Key principles of adverse event investigation, including Human Factors and System thinking and practice elements such as interview techniques, developing a timeline of events, developing effective improvement actions and report writing.
  • The 72-hour review process, including initial debrief, supporting staff, gathering information and notification/reporting requirements.
  • Hearing directly from an NHS organisation recognise as ‘outstanding’ by the CQC about their improvement journey, how progress was achieved and the barriers and challenges.
  • Practical workshops based a video case study so that delegates can practice and use the skills and knowledge gained during the course in practice.
Course Feedback

Our first course took place in London at the end of February and was attended by over 50 maternity professionals from several trusts around the country.

The formal feedback received was extremely positive.

  • 97% of delegates ‘agreed’ or ‘strongly agreed’ that the course had met their learning objectives
  • 87% of delegates rated the quality of education as ‘very good’ or ‘excellent’
  • 93% of delegates said that they intended to modify their practice as a result of the course

Comments from delegates included:

“Extremely informative and interesting 2 days. Excellent speakers – inspiring, thought provoking and will really make me change my clinical practice, how I view my practice and most importantly how I can make a difference to practice.”

 “Excellent. Some really good take home points and some pertinent things that I am really excited to take back to my practice.”

Many of the delegates mentioned that they wished they had received this training earlier in their careers and that they were going to recommend it to the rest of their teams and departments.

The course also generated some great feedback on social media.

 

How to find out more…

We are planning to run this course in June (Manchester), September (Birmingham) and November (South East). For more information about the course and booking information please click here.

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