Onedayawarenesstraining

CourseCoordinator:
Participantsmayattendfortheonedaytrainingonly GeraldineDonaghy
whereitisdeemedthattheymaynotbedesignated
Email:geraldine.donaghy1@hse.ie

investigatorsfortheHSEareabutwhereitishelpful Feidhmeannacht na Seirbhfse Slfilnte

forthemtohaveanawarenessofincident Phone:016352099
Health Service Executive

investigationsothattheymightcontributeoptimally

Quality and Patient Safety Directorate

toinvestigationsastheyariseandwhenthisis
necessary.Theseparticipantsneednotparticipatein
thepracticalmentored/supportedinvestigation
exercisenorthe3monthsnorthe6months
networkinganddebriefingsessions.

4. CourseAward
Doctorswhoattendtheonedaysystemsanalysis
trainingwillreceiveacertificateofattendanceand5
CPD(ContinuousProfessionalDevelopment)credits
fromtheRoyalCollegeofPhysiciansofIrelandand3
CPDcreditsforattendingtheinterimfollowupand
SystemAnalysis
networkingsessionandafurther3creditsfor
attendingthefinalnetworkinganddebriefingsession. Trainingfor
Nurseswhoattendfortheentirecoursei.e.theone
daysystemsanalysistrainingcoursepluscompletethe Investigators
practicalexerciseandattendthe3monthinterim
followupandnetworkingsessionandthe6month
finalnetworkinganddebriefingsessionwillget

10.5CEU(ContinuingEducationUnits)fromAnBord
Altranais.

Trainers
Thecourseisdeliveredbytrainedtrainerswhohave
extensivetrainingandexperienceinmanagingand
investigatingincidentsatlocalandnationallevel,and
extensiveexperienceofwritinglocalandnational
incidentmanagementandinvestigationpoliciesand
guidelines.
Whatisanincident?
Anincidentisaneventorcircumstancewhichcould
have,ordidleadtounintendedand/orunnecessary
harm.Incidentsincludeadverseeventswhichresultin
harmandnearmisseswhichcouldhaveresultedin
harm,butdidnotcauseharm,eitherbychanceortimely
intervention.
Incidentscanbeclinicalornonclinicalandinclude
incidentsassociatedwithharmto:
Outpatients,serviceusers,staffandvisitors
TheattainmentofHSEobjectives
ICTsystems
Datasecuritye.g.dataprotectionbreaches
Theenvironment
Incidentsincludecomplaintswhichareassociatedwith
harmandassuchthesecomplaintsareserviceuseror
staffreportedincidents.
1. Coursepurpose
Thepurposeofthistrainingisthatinvestigatorswill
learnandpracticehowtoconductsystemsanalysis
investigationsofincidentsandcomplaintsinaccordance
withHSEguidelines(HSE2012).
2. Courseobjectives
Theobjectivesofthiscoursearethatparticipantswillbe
ableto:
Organisetheinvestigationandgatherthedata
Determiningtheincidentchronology
Knowwhenandhowtoseekexternalexpertinput
Identifythekeycausalfactorsandincidental
findings
Identifythecontributoryfactors
MakeSMARTrecommendationsaccordingto
thehierarchyofpreferredcontrolmeasures
Writeandsubmitinvestigationreportsthatare
valid,reliableandgeneralisable
Knowwhenandhowtoseeklegalinput/review
3. Coursedurationandcontent
Day1:SystemAnalysisTraining
Thecoursecontentsofthisonedaysystemsanalysis
trainingsessionareasfollows:
Guidelinesforthesystemsanalysis doingthisbytheleadforincidentmanagementinthe
investigationofincidentsandcomplaints(HSE
2012)
Whatanincidentis
Aboutanincidentmanagementteamandits
structureanditsrole
Aboutanincidentinvestigationteamandits
role
fellowtrainees.
SixstepsoftheSystemsAnalysisInvestigation
Guidelines:
Step1: Organisingtheinvestigationand
gatheringthedata
Step2: Determiningtheincidentchronology
Step3: Identifyingthekeycausalfactorsand
incidentalfindings
Step4: Identifyingthecontributoryfactors
Step5: Makingrecommendations
Step6: Writingandsubmittinginvestigation
report.
Whenandhowtoseekexternalexpertinputto
HSEinvestigations
Whenandhowtoseeklegalinput/review
Supportandmentoringforinvestigators
Qualityassuringinvestigations.
PracticalExercise
Theonedaysessionisfollowedupwithapractical
exercisewherebytraineesaregivenanincidentto
investigate.Traineesarementoredandsupportedin
areatheyhavebeennominatedfrom.
Interimfollowupandnetworkingsession
Theonedaytrainingsessionisfollowedupin3
monthsbyaninterimnetworkingsessionwhere
participantscometogethertodiscusstheirpractical
investigationexperienceswiththeirmentorsandtheir
Finalnetworkinganddebriefingsession
Thetrainingconcludeswithafinalnetworkingand
debriefingsession6monthsaftertheinitialtraining
daywhereparticipantscometogethertodiscusstheir
completedinvestigationswiththeirmentorsandtheir
fellowtrainees.