t: 0116 241 8331 e: office@apt.ac
Learning the Lessons from Major Incidents.
Learning the Lessons from Major Incidents is an APT-Accredited 3-day course from one of the UK's leading providers of mental health training. We bring the training to your own organisation, for maximum cost-effectiveness, and up to 15 people can attend. (2-day version and refresher courses are also available.)
Executive Summary:
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.
The course covers:
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.
What you receive as a result of attending the training:
You will be registered as having attended the course, thereby gaining APT's Level 1 accreditation, and receive a certificate to this effect. The accreditation gives you access to online resources associated with the course.
Your registration lasts indefinitely, and your accreditation lasts for 3 years and is renewable by sitting an online refresher which also upgrades your accreditation to APT Level 2 if you are successful in the associated online exam.
Your accreditation is given value by the fact of over 100,000 people having attended APT training. See APT accreditation for full details.
How can I access this training?
Option 1: Bring the course to your organisation:
We bring this course to your own organisation a train a group of 6-15 people for a fixed, all-inclusive fee of £4,390 plus VAT for the 3-day course, or £3,250 plus VAT for the 2-day version.
To book, call (UK) 0116 241 8331, or click the button:
Option 2: 'Train the Trainer':
If you or a colleague are a senior professional (e.g. consultant psychologist) and have a talent for communication and teaching, then you are welcome to apply to become an APT-accredited tutor. You could then tutor the course - or your chosen modules from it - in your own organisation, under license.
This is not only a highly appropriate use of senior professionals, but it also saves your organisation the tutor-component of the fee (around 50%) each time you run it or your chosen modules.
To see the full benefits of this and to see whether you are eligible, click the button:
Downloadable information sheet:
Click here to download a printable information sheet
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Feedback Ratings.
We continuously monitor the quality of our training by obtaining feedback on the two key scales of relevance and presentation from every course delegate. Below are the average ratings for the last two runnings of this course.
Average Presentation rating: 96%
Average Relevance rating: 95%
*These statistics were last updated in September 2018.
Written Feedback.
APT prides itself on the feedback we receive about our courses. Below are just some of the great comments the Learning the Lessons from Major Incidents course has received.
"Fantastic, very relevant … would recommend it for all clinical managers."
"A very thought provoking training course, delivered in an effective and professional way."
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