Module 1: Systems Thinking and the Fundamentals of Patient Safety

In our first module we will introduce the course by reviewing the nature and frequency of medical errors and adverse incidents as well as the three fundamental concepts upon which the contemporary study of patient safety is based: complexity, integration and high reliability. The topics covered in this module include:

• the nature and frequency of near misses, preventable adverse events and medical negligence
• how different healthcare units, functions and providers interact to create complex systems
• how High Reliability Organisations (HROs) such as aviation succeed in avoiding catastrophes in complex and risky environments
• the major challenges and obstacles healthcare organisations face in order to become safer

Module 2: Human Factors and Human Errors

In Module 2 we will explore the cognitive, physical and psychological factors that affect how human beings and health systems interact and discover how we can design safer health systems. The topics covered in this module include:

• human cognition and its impact on clinical reasoning and patient safety
• ‘System 1’ and ‘System 2’ thinking and how they affect the interaction between the clinician and their clinical environment
• the role of human-factors engineering in making care safer
• how improvements in ergonomics and the work environment reduce medical errors and improve clinician safety

Module 3: The Impact of Technology on Patient Safety

Technology has become an integral part of healthcare so in this module we address its impact on patient safety and consider how technology’s benefits can be harnessed without compromising the safety of care. The topics covered in this module include:

• how technologies such as Electronic Health Records (EHRs) affect patient safety
• how people and technology interact and why tech should be treated as another member of the healthcare team
• the impact of Artificial Intelligence on healthcare and how it can be used to improve patient safety
• the limits of technology and how to avoid using tech inappropriately

Module 4: Error Science I – Error Reporting Systems

This is the first of three modules that will take an in-depth look at how errors should be reported, investigated and responded to. We begin by considering the importance of having systems capable of capturing safety issues and concerns. The topics covered in this module include:

• the characteristics of an effective error reporting system
• how to classify errors
• how to improve and optimise error reporting systems in healthcare
• the lessons learned from error reporting systems in other industries

Module 5: Error Science II – Root Cause Analysis

In Module 5 we review, in detail, the skills and knowledge needed to manage and lead a comprehensive patient safety investigation using Root Cause Analysis (RCA). The topics covered in this module include:

• the sources of information that can help us investigate an error or incident
• practical tools and techniques we can use during an RCA investigation to help us map, analyse and understand events
• how to identify acts and omissions in care and service delivery
• how ‘barrier analysis’ can help us identify whether barriers to harm already exist and, if not, how they can be implemented or improved.

Module 6: Error Science III – Quality Improvement

In the third of our error science modules we explore how to undertake an improvement project and how to measure its impact on patient safety. The topics covered in this module include:

• the science of quality improvement: understanding systems, variance, knowledge-building and human psychology
• how the ‘Model for Improvement’ can be used to run successful patient safety improvement projects
• the stakeholders who will be affected by your improvement project and how to select team members
• how to create a project charter that contains detailed information about your improvement project

Module 7: Teamwork and Communication

Effective teamwork and communication both play a critical role in keeping patients safe. In this module we discover why they are important and how we can improve them. The topics covered in this module include:

• the impact of poor communication and collaboration on safety
• what the research evidence tells us about the characteristics of high-performing healthcare teams
• barriers to effective teamwork and communication in healthcare
• tools and techniques for improving collaboration and communication in your team

Module 8: Leading Patient Safety

In Module 8 we consider the critical role the patient safety leader or specialist plays in a healthcare organisation and the skills, knowledge and behaviours that make a high-performing patient safety leader. The topics covered in this module include:

• the role of the patient safety leader or specialist and how it is evolving
• the types of organisational data that should be on a patient safety leader’s “dashboard” and regularly reviewed
• the role of patient safety committees
• how to engage physicians and frontline clinical leaders in improving patient safety

Module 9: Creating a Culture of Safety

A culture in which every caregiver values patients and their safety is the aspiration of all progressive healthcare organisations. In this module we discover why this aspiration can, however, be elusive and consider what it takes to create and sustain a genuinely ‘just culture’ that facilitates exceptional safety standards. The topics covered in this module include:

• what is a ‘just culture’ and how does it contribute to patient safety?
• how to assess and enhance the effectiveness of your current safety culture
• how to incorporate the concepts of ‘Safety II’ and ‘Appreciative Inquiry’ into your practice in order to learn from and celebrate success
• disclosing errors and supporting patients, families and caregivers

Module 10: Patient-Oriented Safe Care

The final module of this course considers what safe care means for patients and their families and how we can take a more patient-centred perspective on matters of safety. The topics covered in this module include:

• how effective communication with patients improves their safety
• techniques for communicating more effectively with patients and their families
• understanding and respecting the patient’s priorities for safe care