{
  "abstract": "Background NHS England published the learning response toolkit in the Patient Safety Incident Response Framework (PSIRF) in 2022 which promoted a range of systems-based approaches to learning from patient safety events. An After Action Review (AAR) provides a simple structured approach using a four question model (1. What did we expect to happen?; 2. What actually happened?; 3. Why was there a difference?; 4. What has been learnt?) to promote team learning, reflection and improvement. In 2023 the organisation adopted the principles and specifically AAR as its learning methodology across the organisation both clinically and corporately.Aims To adopt a simple to use, structured approach to learning from significant events or where there is significant learning, not restricted to clinical patient safety events. To support staff to reflect and learn from events in a psychologically safe, facilitated meeting where the focus is on learning and improvement, not blame. To support organisational learning supporting improvement in patient experience, effectiveness and patient safety.Methods Identified an experienced facilitator who accessed training videos/reading from another organisation. Identified an event where learning could occur (a symptom management stay). Introduced the concept to the assembled team, setting ground rules, clearly explaining that the meeting focus was about learning. The use of the tool was evaluated after the meeting.Results The model was felt to be useful. The structure and facilitated nature meant staff felt able to say what they thought. It led to positive changes to the acceptance and admission of patients for symptom management improving efficacy and experience. Question 3 has been amended to include what went well during the event.Conclusion AAR has been successfully adopted as the learning response across the organisation and since 2023 thirteen AARs have been held including clinical incidents and learning around other organisational functions such as catering, recruitment and service development.",
  "authors": [
    {
      "affiliations": [
        "Rainbows Hospice, Loughborough, UK"
      ],
      "name": "Anne-Marie Murkett"
    }
  ],
  "title": "P-91 Adopting after action reviews as a learning event in a children’s hospice",
  "uid": "abf3d263-1861-567d-90ba-eb44119f9cd4"
}