Patient Safety Healthcare Learning Pathway Level 2 Module 3, Incident Investigation

This course will prepare you to manage fatigue in your organisation in a systematic way. It will demonstrate why fatigue management is a priority for anyone involved in road transport, explain the scientific principles for effective fatigue management and give you a range of tools to use to tailor interventions to the needs of your organisation.

Level 1 - Human Factors can help all of us in our job roles. Understanding more about Human Factors helps us to, understand why work goes well, improve information and workflow, improve the design and usability of health and social care systems, equipment, and technology, enhance teamwork and improve communication between different groups of staff in your own organisation and across care settings, understand why things go wrong and consider what could go wrong in the future.

Course C ‘Understanding the cultural, legal, and regulatory issues’ is the third course (C) in the delivery of the Patient Safety Syllabus (Levels 3 and 4) . It follows Course A (Unpacking the Systems issues) and Course B (Managing Patient Safety Risks). Course C outlines the development of safety culture in the NHS (England), including patient safety inquiries, safety measures, and initiatives. Legal and regulatory frameworks are outlined, including clinical negligence, duty of candour, and the requirements of a coroner inquest. The teaching faculty includes senior clinicians from NHS Resolution, Health Services Safety Investigation Branch (HSSIB).

Course D Involving those affected is the fourth course in the delivery of the Patient Safety Syllabus (Levels 3 and 4). It follows Course A (Unpacking the Systems issues), Course B (Managing Patient Safety Risks), and Course C (Understanding the cultural, legal and regulatory factors). Course D has been developed to outline the issues for those affected in patient safety events in the NHS (in England) as part of the delivery of the Patient Safety Syllabus1.

Medical Devices and Digital Interfaces In this module you will apply your learning about HFE systems and task analysis for testing and evaluation (including simulation) of equipment, software, controls, visual displays, etc. You will use your growing knowledge about human capabilities/limitations and apply HFE methods to enhance health, safety, comfort, motivation, usability, effectiveness, and efficiency. Where you identify potential and existing high-risk tasks and activities, you will be encouraged to integrate HFE principles and concepts into the design of systems, interfaces, and products supported by published examples of HFE case studies from the teaching faculty.

This module aims to help develop nuanced understanding of risk management and resilience engineering in healthcare. You will be introduced a range of different risk types that exist in healthcare and appropriate risk management strategies. You will consider key stages of risk management and conduct a group work applying SEIPS-based safety assessment. The model of the Concept for Applying Resilience Engineering will be introduced in details and be used for a group work assessing and improving resilience abilities of the healthcare system.

The module on leadership and non-technical skills is meant to provide the attendee with insight into leadership as a process versus a leader as a person. It draws upon an individual's traits, personality and emotional intelligence as factors that interplay with their technical understanding of HFE based process design. This is to allow further exploration, critique and appreciation of leadership in complex adaptive systems such as healthcare. It offers a balanced insight of individual versus system resilience in delivering outcomes for quality and safety.

This short course provides training on the development of work procedures such as written instructions, checklists, and flow charts to create safer and easier to use procedures, and reduce risks to healthcare staff, patients, carers and others. Ten key guidance points are outlined for all stages of development, implementation and review, (1) What is a Work Procedure?, (2) Ensure a Procedure is needed, (3) Involve the whole team, (4) Identify the hazards, (5) Capture work-as-done, (6) Make it easy to follow, (7) Test it out, (8) Train people, (9) Put it into practice, and (10) Keep it under review.

Disseminating Information is a key activity in promoting safety in healthcare. You will learn about 12 Tips for educators including the systems framework, HFE tools and competency, misunderstandings, and ideas for implementation to enhance the effectiveness of safety and improvement work in frontline healthcare practice. This will include thinking about systems and cultures for different audiences and discussing how to address myths and misunderstandings about HFE in healthcare. The synergies between Quality Improvement (QI) and HFE will be explored as part of the learning organisation, and you will be encouraged to ‘build on what is already there’.

This module will outline environmental factors that contribute to physical well-being including working conditions (e.g., acoustic, thermal visual vibration) and exposure to musculoskeletal risks. You will look at how people interact with their environment and consider how workplace/task design can result in awkward working postures and risk of injury. You will learn and practice two core HFE methods, postural analysis (OWAS) and anthropometry (body shape and size). You will be encouraged to use these tools to evaluate human performance and design safer working environments and tasks.