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Improving Patient Safety: After Action Reviews

An After Action Review is a facilitated discussion following an event to understand what happened and why, and how it could be improved from the perspective of those who were involved. There is an emphasise on facilitation of active awareness and self learning to lead to lasting change and improvement. AARs are included as an investigation and learning tool under the Patient Safety Incident Response Framework (PSIRF).

Chair’s Introduction and Welcome: After Action Reviews

• developing an effective AAR process

• engaging people and developing active learning

• the practicalities and framework of an effective AAR

• setting the ground rules: ensuring an environment of honesty and psychological safety

• understanding the potential barriers to AARs in clinical settings

 This session will include small group work


Mr Stephen Ashmore

Mr Stephen Ashmore

Director, Clinical Audit Support Centre

Stephen started working in clinical audit in 1995 and holds several relevant professional qualifications. He is a co-Author of Principles for Best Practice in Clinical Audit and with Tracy developed the nationally recognised Clinical Audit Teaching Toolkit. Over the years, Stephen has served on national audit committees and as a Patient Participation Group chairman. His spare time is consumed by a 4 year old.

Ms Tracy Ruthven

Ms Tracy Ruthven

Director, Clinical Audit Support Centre

Tracy has worked in clinical audit and improvement for almost 30 years. She held several key posts in the NHS before setting up CASC in 2006. Tracy holds a Masters in Managing Quality and serves as Freedom to Speak Up Guardian for an outstanding CQC-rated hospice. She speaks at many national conferences, is widely published and loves delivering training. In her spare time serves as a magistrate.



• understanding when AARs should be used and when they should not

• developing criteria for full investigation v after action reviews

• implementation of safety improvement practice

• embedding learning in response to patient safety incident investigation

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Dr Samantha Machen

Dr Samantha Machen

Head of Patient Safety Incident Response & Associate Director of Patient Safety, University Hospitals Sussex NHS Foundation Trust

Sam completed an undergraduate Masters of Nursing Science (MNurSci) degree at the University of Nottingham before working as a qualified intensive care nurse at the East Midlands Major Trauma Centre in Nottingham. She later completed a MSc at the London School of Economics and Political Science in International Health Policy and Health Economics.

She was awarded a Health Foundation Improvement Science fellowship to complete her PhD at University College London. Sam’s PhD focused on safety science and human factors and used ethnographic methodology to understand systems of work for medication safety and explored how professional and organisational culture affects the governance of safety. Sam has presented her research across the U.K. and worldwide and is a contributor to multiple peer-reviewed journals on patient safety, culture, and research methods.

Sam has an honorary research status with UCL and leads the teaching on their Patient Safety MSc course for MSc students focusing on quality and patient safety. She currently works for University Hospitals Sussex as Associate Director for Patient Safety and responsible for rolling out PSIRF across all sites. Most recently, her research focus in safety has been focused on how organisations can thematic review incidents using systems-based classification codes to ensure adequate system – not person – focussed learning.

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