Patient Safety Competencies Curriculum Development

Domain 1: Contribute to a Culture of Patient Safety

Key and enabling competencies:

1. Health care professionals who commit to patient and provider safety through safe, competent, high-quality daily practice.

1.1. Are able to articulate their role as individuals, as professionals, and as health care system employees in providing safe patient care

1.2. Act as role models and champion patient-safety behaviours

1.3. Recognize personal limitations and ask for assistance when required

1.4. Demonstrate knowledge of policies and procedures as they relate to patient and provider safety, including disclosure

1.5. Report unsafe processes within the health care system

1.6. Participate actively in event and close call reporting, event analyses and process improvement initiatives

1.7. Exchange feedback with colleagues on safety issues on an ongoing basis in an open manner

1.8. Integrate safety practices into daily activities (e.g., hand hygiene)

1.9. Recognize clinical situations that may be unsafe and support the empowerment of all staff to resolve unsafe situations

1.10. Demonstrate a commitment to a just culture, promoting fair approaches to dealing with adverse events

1.11. Advocate for improvements in system processes to support professional practice standards and the best patient care

2. Health care professionals who are able to describe the fundamental elements of patient safety, understand:

2.1. Core theories and terminology of patient safety and the epidemiology of unsafe practices

2.3. The use of evaluative strategies to promote safety

2.4. The risks posed by personal and professional limitations

2.5. Principles, practices and processes that have been demonstrated to promote patient safety

2.6. The nature of systems and latent failures in the trajectory of adverse events

2.7. The emotional impact of adverse events on patients, families and health care professionals

2.8. Methods by which health care professionals can advocate for patient and health care system safety

2.9 The elements of a just culture for patient safety, and the role of professional and organizational accountabilities

2.10. The concept that health care is a complex adaptive system with many vulnerabilities, (e.g., space or workplace design, staffi ng, technology)

3. Health care professionals who maintain and enhance patient safety practices through ongoing learning:

3.1. Identify opportunities for continuous learning and improvement for patient safety

3.2. Refl ect on actions and decisions continuously, with self-awareness and using self-evaluation, to improve knowledge and skills in patient safety

3.3. Analyze a patient safety event and give examples on how future events can be avoided

3.4. Participate in patient and health care professional safety education

3.5. Share information on adaptations to practices and procedures that increase safety for specific individuals or situations

3.6. Contribute to the creation, dissemination, application, and translation of new health care system safety knowledge and practice

3.7. Participate in self- and peer assessments reflecting on practice and patient outcomes

4. Health care professionals who demonstrate a questioning attitude as a fundamental aspect of safe professional practice and patient care:

4.1. Recognize that continuous improvement in patient care may require them to challenge existing methods

4.2. Identify existing procedures or policies that may be unsafe or are inconsistent with best practices and take action to address those concerns

4.3. Re-examine simplistic explanations for adverse events to facilitate optimal changes to care

4.4. Demonstrate openness to change

Learning objectives:

Knowledge

To learn and understand:

1. Key patient safety concepts, core theories and terminology, such as adverse events, close calls, no-harm events and just culture
2. The potential risks presented by one’s own daily practice, and ways to minimize those risks
3. Health care as a complex adaptive system; types of organizational cultures, as well as the characteristics of high reliability organizations and how they relate to health care
4. The contribution of system failures and provider performance to adverse events and close calls
5. Systems-based approaches to reducing system failures

Skills

1. Recognize and respond appropriately to potential and actual unsafe clinical situations
2. Work within their own limitations

Attitudes

1. Commitment to patient safety as a key professional value and an essential component of daily practice
2. Value professional learning as a life-long process requiring self-assessment and self-directed education
3. Demonstrate a questioning attitude in routine and non-routine activities
   

Content:

1. The Defibrillator Misadventure Case Study
2. The Defibrillator Misadventure Facilitator Guide
3. Patient Safety Systems Approach - Primer - PowerPoint
4. Patient Safety Systems Approach - In Depth - PowerPoint
5. David Marx Just Culture Slide Deck and Primer
6. Epidemiology Primer PowerPoint
7. Epidemiology In Depth PowerPoint`
8. High Reliability Organizations- Primer - PowerPoint
9. High Reliability Organizations - In Depth - PowerPoint
10. An Introduction to Patient Safety Nomenclature - PDF
11. Journal Club - Incident Reporting & Trigger Tools - In Depth - PowerPoint
12. CPSI Root Cause Analysis Framework
13. Reporting Adverse Events - In Depth - PowerPoint
14. Reporting Adverse Events - Primer - PowerPoint
15. Domain 1 Introduction (includes systems approach, epidemiology, high reliability organizations and reporting adverse events) - PowerPoint

Teaching methodologies:

Suggested lesson plans for academic half day interactive sessions:
(see Attachments below for teaching material)

1.    Three Hour Session:

• Domain 1 presentation (ppt)
• Discussion of "Marx Just Culture" primer (pdf)
• The Defibrillator Misadventure & Facilitator Guide

2.    Two Hour Session:

• Discussion of "patient safety and the just culture - Marx" (pdf)
• Case Study (The defbrillator miadventure and facilitator guide)

3.    Two Hour Session:

• "PCCReportingAdverseEvents" power point presentation
• "JournalClubIncidentReport&TriggerTool: power point presentation
  

4.    Selection of 1 hour Sessions (chose one of the following):

• Methods of detecting error and adverse event (PCCReportingAdverseEvents ppt)
• "JournalClubIncidentReport&TriggerTool: power point presentation
• Epidemiology of Error (EpidemiologyFinalppt)
• Patient safety systems approach (PatientSafetySystemsApproachPCC2 ppt)
• High Reliability organizations - (HighReliabilityOrganizationsPCC2 ppt)
• Defibrillator Misadventure case and facilitator guide
• Patient safety and the just culture - Marx - discussion of pdf
  

5.    Selection of Short-Snappers (may combine as required):

• Methods of detecting error and adverse event (ReportingAdverseEvents Primer.ppt)
• Epidemiology of Error (EpidemiologyPrimer.ppt)
• Patient safety systems approach (PatientSafetySystemsApproachPrimer.ppt)
• High Reliability organizations - (HighReliabilityOrganizationsPrimer.ppt)
• Discussion of "Marx Just Culture" primer (pdf)
  

Evaluation:

Learner

• Jeopardy quiz
• 'Card' questions RCPSC format

Program/session/module

Supporting materials/videos:

PDSA and FMEA Science:

• ISMP FMEA Tool
• Reducing Medication Errors Through FMEA - Video $125.00 at ISMP
  
• IHI FMEA Tool - This is a free download but you must register with IHI
• Rapid Cycle Improvement with PDSA - CPSI Forum, April 30,2009 Eileen Patterson MCE - PowerPoint

Emotional Impact of AE on Patients Families and Health Care Professionals:

• Albert Wu: 2nd Victim - BMJ Article available for download
  
• Rick van Pelt: Peer Support - Article available for download
• Beyond Blame - Video $45.00 at
  

Domain 1 Attachments

CPSI RCA framework.pdf
Epidemiology PRIMER - Anne Matlow & Sue Tallett 060309.pdf
Epidemiology of Adverse Events - Anne Matlow, Sue Tallett.pdf
High reliability organizations - Anne Matlow PCC2.pdf
High reliability organizations PRIMER - Anne Matlow.pdf
Introduction to Patient Safety - Domain 1 Presentation.pdf
Journa Club - Incident Report & Trigger Tool - Dawn Hartfield.pdf
Marx Just Culture Primer.pdf
Patient Safety Nomenclature.pdf
Patient Safety Systems Approach PCC2 - Anne Matlow.pdf
Patient Safety Systems Approach PRIMER- Anne Matlow.pdf
Patient Safety and the Just Culture - David Marx.pdf
Reporting Adverse Events - Dawn Hartfield.pdf
Reporting Adverse Events PRIMER - Dawn Hartfield.pdf
The Defibrillator Misadventure Case Study.pdf
The Defibrillator Misadventure Facilitator Guide.pdf