Topic |
Learning Objectives |
Presenter |
Introduction to Patient Safety |
- Know the frequency/cost of adverse events worldwide (Ex. to Err is Human).
- Recognize that adverse events are a common cause of death in hospitals.
- Describe efforts to date to address adverse events and results.
- Understand safety from viewpoint of the patient.
|
Paul Sharek |
From Error to Harm |
- Describe the difference between error and harm.Establish the link between human error and harm (ex. Swiss cheese model).
- List three unsafe acts (Ex. James Reason model).
|
Qianli Jiang |
Human Factors and Patient Safety |
- To understand the key principles of Human Factors and Ergonomics science.
- To be able to describe how the Human Factors and Ergonomics approach to safety (most effective to least effective).
- To have an appreciation of where Human Factors and Ergonomics could and should be considered to improve systems design and human interfaces/interactions.
|
Sue Hignett, Thomas Jun & Mike Fray |
Effective Teamwork & Communication |
- Advise your institution on how teamwork can contribute to quality and safety of care
- Describe the key contents of a teamwork training program
- Explain elements of effective structured communication tools to decrease risk
|
Anthony Staines
|
Responding to Adverse Events |
- State the immediate next steps to be taken after an AE occurs.
- Describe two elements of an effective disclosure of an AE to a patient/caregiver
- Define what the term "Second victim" means.
|
Albert Wu |
Root Cause Analysis (RCAs) |
- Explain Root Cause Analysis (RCA) and its purpose.
- Show how an RCA can be used to prevent harms in the future.
- Name an event that would be appropriate for an RCA.
|
Peter Lachman
|
Failure Modes and Effects Analysis (FMEAs) |
- Understand the five “Whys” and when an FMEA would be used.
- State how to assess the relative impact of failure on each component of the process.
- Describe the approach to identifying "high risk" components of the process being evaluated in the FMEA.
|
Paul Rafferty |
Healthcare Standards |
- Define healthcare standards including common patient care and management standards and how they are applied clinically.
- Understand the difference between awards, accreditation, regulation and peer review.
- Know what structures are necessary and the importance of processes to the delivery of high quality and safe patient care.
|
Stephen Clark |
Building a Culture of Safety |
- Identify the three critical components of a culture of safety (ex psychologic safety, transparency, supportive leadership).
- Explain can be done to create a culture of safety.
- List the clinical outcomes that have been improved with a strong culture of safety.
- Articulate how do measure (what are the attributes of) the culture of safety in their own organisations.
|
Christina Krause |
Just Culture |
- Describe what is meant by a "fair and just culture".
- Understand what the word "reckless" means and how it relates to patient safety.
- Explain how a healthcare organization with a just culture would respond when a staff member has excessive workload.
|
Sidney Dekker |
Person-Centred Care |
- Understand the concept of Patient-Centred Care
- Discuss how to implement effective Patient-Centred Care
- Give examples of how we can deliver Patient-Centred Care
|
Kris Vanhaecht |
Measuring Patient Safety |
- Name three ways to measure patient safety
- Identify two strengths and two weaknesses of occurrence reporting
- Explain what a trigger is and identify one strength and one weakness of using "trigger tools" to measure safety
- Describe the Framework for safety measurement
|
Peter Lachman |
Understanding Healthcare as a Complex System |
- Understand the complexity of the health care system
- Differentiate between Safety and Quality in health care
- Understand risk and harm through the patient's eyes
- Describe different models of safety
- Consider the balance of benefit and harm within an episode of care
|
Rene Amalberti |
Understanding and Managing Clinical Risk |
- Understand the complexity of the health care system
- Differentiate between Safety and Quality in health care
- Understand risk and harm through the patient's eyes
- Describe different models of safety
- Consider the balance of benefit and harm within an episode of care
|
Bruno Lucet |
High Reliability |
- List the five attributes of a high reliability organization
- Explain what the word "resilience" means in the context of high reliability.
- Describe "situational awareness" and give an example of how this attribute can improve patient safety.
|
John Brennan |
Change Management |
- List the levels of "adopters" in the Rogers model of "the diffusion of innovation"
- Discuss the value of a "pilot test"in managing change.
- Name three techniques that increase the likelihood that change will be adopted
|
Lynne Maher |
Clinical Applications of Patient Safety Theory - Part 1 |
- Define what a bundle is.
- Understand the bundle elements for preventing Central Line Associated Blood Stream Infections
|
Eyal Zimlichman |
Clinical Applications of Patient Safety Theory - Part 2 |
- Understand the bundle elements for preventing Pressure Ulcers
- Describe the decrease in patient falls that occurs when the pressure ulcer prevention bundle is adhered to at least 90% of the time.
|
Peter Lachman |
Medication Safety |
- Identify at what stage of the medication process most harm occurs. (Administration).
- Describe 2 ways that technology can improve (and 2 ways that it can worsen) the safety of the medication management process
- Describe the frequency, and severity, of medication related harm in hospitals
|
Terri Warholak |
The WHO Medication Safety Challenge |
- Describe and understand WHO Medicine Safety Challenge
|
Shin Ushiro |