Patient Safety Competencies Curriculum Development

Domain 4: Manage Safety Risks

Key and enabling competencies:

1. Health care professionals who recognize routine situations and settings in which safety problems may arise:

1.1. Demonstrate situational awareness by continually observing the whole environment, thinking ahead and reviewing potential options and consequences

1.2. Recognize safety problems in real-time and respond to correct them, preventing them from reaching the patient

1.3. Employ, as appropriate techniques such as diligent information-gathering, cross-checking of information using checklists, and investigating mismatches between the current situation and the expected state

2. Health care professionals who systematically identify, implement, and evaluate context-specifi c safety solutions:

2.1. Critically appraise the literature to identify evidence-informed and emerging safety solutions

2.2. Learn from local successes and experiences, assessing their appropriateness to a work setting

2.3. Select the most appropriateiate solution for a given context, taking into account quality, resources, practicality and patient preferences

2.4. Refl ect on the impact of an individual intervention, including the potentially harmful or unintended consequences of a safety intervention

2.5. Evaluate the ongoing success of a safety intervention by incorporating lessons learned

3. Health care professionals who anticipate, identify and manage high-risk situations:

3.1. Recognize health care settings that may lead to high-risk situations

3.2. Respond eff ectively by means of effi cient task and process management, crisis team functioning, and dynamic decision-making

3.3. Participate in ongoing training, such as simulations to enhance abilities to manage high-risk situations

Learning objectives:

Knowledge

To learn and understand:

1. System design and its impact on event evolution
2. Safety practices that reduce the risk of adverse events, such as:
   • Infection control, including:
   • aseptic technique,
   • hand hygiene,
   • screening and surveillance
   • Injury prevention, including;
     • safe patient transport,
     • handling and transfers, and
     • the removal of physical hazards
   • The safe administration of medication, including;
     • standardization of drug formulations,
     • recognition of sound-alike and look-alike medications,
     • abbreviation pitfalls,
     • medicatio reconciliation,
     • proper preparation,
     • reliable patient identification and alerts
   • Risk awareness, including;
     • situational awareness
   • The purpose of redundancy in clinical processes:
     • medication checking,
     • allergy checking,
     • wrong-side checking,
     • checklists and buddy systems
   • Standardization of approaches and processes (e.g., evidence-informed practice guidelines and checklists)

Skills

1. To anticipate and recognize problems on the level of individuals and of systems
2. To respond to safety-related situations
3. To monitor, track and re-evaluate system failures, potential cognitive pitfalls of health care providers, and the clinical status of the patient
   

Attitudes

1. To exercise vigilance on safety issues
2. To participate in risk analysis as appropriate
3. To advocate for patient safety

Content:

1. Enabling competency 1 is addressed at a high level in the ppt presentation below called Domain 4: Enabling Competency 1
2. Word document Content Domain 4 addresses systems, error and high rerliability (briefly) and medication management. Citations from Berwick, Reason and Vincent are included. Questions are embedded as is a case discussion.
3. Infection control through a patient safety lens is addressed in the ppt presentation DRAFTInfection control through a patient safety lens.
4. Crew resource management and human factors

Teaching methodologies:

1.     Session 1: 1-2 hours

• Discussion of case
• Use of slide deck 'Domain 4 Enabling Competency 1"- reflective questions are provided in this deck

2.     Session 2: 1 hour

• Use 'crew resource management slide deck to introduce high reliability organizations
• Discuss experiences from these 'case studies' in aviation and how we can learn from them in health care
• Suggest Helmreich CRM paper enclosed below as pre or post read for this session

3.     Session 3: 1 hour

• Pre-read Reason's Human Error paper, included below, and discuss
• Use cases in content domain 4 document for discussion

4.     Session 4: 1 hour

• Explore infection control issues- use slide deck 'Infection control through a patient safety lens'
• Discuss local issues of infection control
• Suggest Provonost NEJM article Dec 2006, included below, as pre or post reading

5.     Journal club: 1 hour

• Use paper included below on risk reduction for adverse drug events through sequential implementation of patient safety initiatives in a Children's hospital: critique of paper and discussion of measures to reduce adverse drug events

Evaluation:

Learner

Program/session/module

Supporting materials/videos etc

PPT presentations as per below.

Domain 4 Attachments

Checklist case Domain 4-facilitator guide.pdf
Checklist case Domain 4.pdf
Content Domain 4 - Anne Matlow.pdf
Crew Resource Management HRO ppt - Anne Matlow.pdf
Domain 4 Enabling Competency ppt - Anne Matlow.pdf
HUMAN FACTORS ppt - Anne Matlow.pdf
Helmreich CRM.pdf
Human Error Reason.pdf
Infection Control Through a Patient Safety Lens PPT - Anne Matlow.pdf
Pronovost+2006+ICU+CLI+Paper.pdf
Leonard ADE OCt 06.pdf