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A 3-day course for 6-16 people.
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Overview and Course Aims:
In mental health and related areas there are a number of ‘major incidents’ that can occur,
most notably to do with people losing their lives through suicide, violence or neglect, but
also relating to sex offending and a whole range of serious but less tragic events. After a
serious incident there often seem to be obvious ‘oversights’ or mistakes, although some of
these can be put down to the wisdom of hindsight. This important course aims to equip
managers to examine such incidents and to draw the real lessons from them, while also distinguishing those lessons from ‘the wisdom of hindsight’. Vitally, the course highlights the importance of ‘free lessons’ where serious consequences were avoided more by luck than
by judgment. One of the major methods on the course is to learn the principles of analysis
by examining major incidents from other areas – road traffic accidents and air crashes – and
then to apply those same lessons to mental health and related areas.
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The course covers the following:
Overview
• Human Error: “The notion of a root cause seems to be an over simplification. Usually there
is a chain of events and a wide variety of contributory factors leading up to the eventual incident.” Taylor-Adams and Vincent.
• Learning lessons needs to be quick, easy – and right: A Simple 5-step Process.
• Who Sets an Investigation in Motion?
• Don’t underestimate the kitchen table.
• Team or solo investigations?
• Keeping Other People Involved.
• Learning the Lessons: The 4 Key Principles.
How to investigate
• Naive investigators imagine that incidents choose themselves. In fact some of the best
lessons are learned by opting to examine ‘near misses’.
• Sometimes it’s chosen for you, other times you can choose it. Always be the latter; that’s
what differentiates a learning organisation from others.
• How do you investigate a ‘near miss’? Nothing happened, after all!
• A key ability in learning individuals: being able to spot incidents that were “almost a
near-miss”!
Finding out about the incident
• Good Information is Vital. As the old saying goes: ‘Garbage in, garbage out.’
• The four key sources of information.
• In interviewing people, your Attitude is Key.
• Open Questions and Requests.
• Requests for Opinions.
• Leading Questions, e.g. the ‘forced choice’ question, are not OK.
• ‘Transparent questions’ are perfectly legitimate to ask – how and why.
• Closed Questions are important and under-rated.
Writing a clear account of the incident
• Without a clear, accurate account of what happened, anything that follows is undermined.
This involves (a) getting good information and (b) setting it down clearly.
• The two ways: A narrative account and a time line.
Identifying what would have prevented the incident
• Catastrophic Incidents usually occur as a result of a sequence of small events that
accumulate to create a more serious situation.
• Catchpole, K.(2009).
• Develop “If only … ” statements.
Identifying Recommendations
• Blaming individuals is emotionally more satisfying than carefully thinking through recommendations that will be to the organisation’s benefit. After Reason, J.(2000).
• Examples of ‘system’ recommendations.
• Will Your Recommendation really Improve Matters Overall?
• Permanent-ising Your Recommendations.
• Rules for making sound judgments.
• Traps to avoid: The risky shift. The omnipotence trap. The ‘appointed expert’ trap. The ‘someone must be to blame’ trap. The scapegoating trap. The plausibility trap. The
hindsight trap.
• Important concepts to bear in mind in writing your recommendations.
Teaching methods include: lecture, discussion, video material, case study analysis of major incidents, practice exercises.
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A 3-day course for 6-16 people.
We bring the training to you for an all-inclusive fee of £4,195 plus VAT.
Target Training Day also available on this topic – see Targeted Training Days.
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"Fantastic, very relevant ... would recommend to it for all clinical
managers."
Appiah Okinka, Senior Nurse
"Very informative and empowering."
Michael Sarfo-Bans, Ward Manager
"The course was excellent."
Maureen Cushley
"This was positive and uplifting training
that I believe is necessary for all mental health workers to go on."
Adam Cook, Occupational Therapist **
"This was one of the best courses I
have ever been on in a career spanning twenty years ... I very much hope that it
will be 'rolled out' to other trust employees so that it will help us all to share similar perspectives and language."
Christine Little, Course Delegate **
"One of the most motivating, engaging
and professional training seminars I've been to. The facilitator not only had a
great deal of credibility in the subject,
but an ability to really facilitate learning, questioning and practicing ... will be recommending it to my colleagues."
Tania Nicholls, Senior IOT **
"Really enjoyed the 3-days ... the whole course content is very though provoking and the accompanying workbook is thorough and well presented. An
excellent course to attend - thanks!"
Pam Abbey, Nurse Practitioner **
"Best Course I have ever attended,
will greatly benefit from having learnt
about how to overcome and anger and irritability. No criticisms whatsoever."
Course Delegate, Social Worker **
"I have greatly enjoyed the course and it will be greatly beneficial to my working practice. The model given is very usable and can be transferred to other issues as well as anger and aggression."
Eve Wicks, CPN **
"Positive and uplifting training that I
believe is necessary for all mental
health workers to go on."
Adam Cook, Occupational Therapist **
**This course is new, these comments
have been taken from other courses
within
the Risk specialism.
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