PATIENT SAFETY
COURSE
IMPLEMENTING A SYSTEMS APPROACH TO PATIENT SAFETY
Who should attend
The course is for individuals who have responsibility for patient safety in healthcare organizations, including patient safety managers and staff, clinical leads for patient safety, and senior staff responsible for clinical governance functions, including patient safety.
What you learn
Traditional approaches to patient safety in healthcare organizations are not working effectively and fast enough to make patient care significantly safer. The course incorporates the rapidly expanding evidence base on patient safety and covers:
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changes in direction for patient safety and what is behind the changes
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how the safety of patient care has been measured internationally and key findings
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concepts and terms involved in a systems approach to patient safety
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the proactive and reactive components of a patient safety programme
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principles of human factors engineering including types of causes of failures in patient safety, including the Systems Engineering Initiative for Patient Safety (SEIPS)
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the differences between Safety I and Safety II
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how incident reporting and previous approaches to incident analysis fail to prevent recurrences of the same incident
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how assessing and managing risk effectively contributes to patient safety
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how failure mode and effects analysis can contribute to proactive patient safety
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influences in the organization's culture that can affect the safety of patient care
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how patients can contribute to patient safety
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how staff contribute to patient safety.
Extensive international studies that have measured patient safety and revealed the incidence and preventability of harm to patients and potential contributors to harm are described in the course. Also included are recent evidence-based practices that contribute to patient safety from large-scale systematic reviews; proactive and reactive methods for analysing how to make systems and processes work more safely; ways to measure, monitor and improve patient safety; how patients can and should be involved in reporting and analysing incidents and concerns and contributing to improving patient safety; and the strategy, learning systems, culture and support needed in an organization to make patient safety an organizational priority.
Concepts including the contribution of human factors to safe patient care, Safety I versus Safety II, the effects of distractions or interruptions to the safety of completing a clinical task, and the analysis and reliability of healthcare systems are embedded in the course. Participants practice proper systems-based analysis of an incident as well as how to proactively prevent an incident. The content in the course acknowledges — and extends — the learning outcomes and content in the Patient Safety Syllabus from the Academy of the Medical Royal Colleges.
Each participant in the course receives an extensive Patient Safety Manual that includes summaries of relevant evidence, step-by-step guidance on how to carry out effective patient safety systems, and practical work to carry out during the course.
Certificates of completion of the course are provided.
PATIENT SAFETY
WORKSHOP
USING INCIDENT ANALYSIS
TO IMPROVE PATIENT SAFETY
Who should attend
The workshop is designed for clinical staff and managers of clinical services who have responsibility for leading analyses of incidents in their services. Patient safety, risk, and clinical governance managers and facilitators will benefit from participation in the workshop.
What you learn
Clinical teams have to be able to analyse serious incidents or near misses that occur in the delivery of patient care as part of an effective patient safety programme. Some clinical groups have developed an open and inquiring attitude toward the analysis of events that harm or could harm patients or staff. But clinical teams and clinical service managers benefit from learning a structured approach to carrying out the analysis and acting to improve patient safety and including patients or their representatives
Each participant receives a 110–page book, Using Incident Analysis to Improve Patient Safety, on the analysis process and a copy of an Incident Analysis Workbook that structures the work carried out during the workshop on an actual incident.
Certificates of participation in the workshop are provided.
The workshop is Certified as conforming to Continuing Professional Development (CPD) requirements in the UK by The CPD Certification Service.
WHAT PEOPLE SAY ABOUT THIS WORKSHOP
‘A very informative day delivered at a perfect level.’
‘Thoroughly enjoyed the workshop and learned a lot.’
‘Very good workshop. It covered a subject that I found very useful.’
‘Lots of examples given along the way to the theory. This helped. Excellent workshop.’
‘Great workshop. Very informative. Will help greatly in my role’
‘An excellent course. The facilitator was very informative and thought-provoking’
‘Very informative critical analysis’
PATIENT SAFETY
WORKSHOP
HOW TO TEACH INCIDENT ANALYSIS
Who should attend
The workshop is for staff who are expected to teach clinical staff and managers how to carry out an analysis of an incident or a near miss in their healthcare organizations. Patient safety, risk and clinical governance managers and staff also will benefit from participation in the workshop.
What you learn
Many healthcare professional staff think of analysis of an incident as an investigation. The outcome of many investigations has been an explanation of how things went wrong, with a plan to act on the findings.
But done properly, an incident analysis is more appropriately an analytic method to identify failures in systems that can affect the safety of patient care. The outcome of a properly carried out analysis should be measured evidence of an improvement in patient safety, an improvement that has happened through one or more effective changes in systems that impact on patients or patient care.
This workshop is about teaching incident analysis properly, including what it takes from a teaching perspective to have learners that are successful in carrying out new processes and practices. Behavioural learning objectives, learner needs analysis, giving clear demonstrations, helping learners through practice based on a workplace situation, and reflections on learning all are covered in this workshop in detail. Practical points such as arranging for teaching sessions, evaluating their success and acting on evaluation feedback also are included.
Each participant receives a 116–page book, How to Teach Incident Analysis.
Certificates of participation in the workshop are provided.
WHAT PEOPLE SAY ABOUT THIS WORKSHOP
‘How to organize a session. Excellent teaching package.’
‘The workshop did exactly what it “says on the tin”.’
‘I found this workshop very useful.’
PATIENT SAFETY
WORKSHOP
FAILURE MODE
AND EFFECTS ANALYSIS
Who should attend
The workshop is designed for clinical staff and managers of clinical services who have responsibility for leading patient safety in their services.
What you learn
Some staff are realizing that it is better to proactively prevent harm to patients than to carry out analysis of individual serious incidents that have harmed patients. The occurrence of the incident means that a patient may have already had an unnecessary negative experience that possibly could have been prevented.
Our workshop on failure mode and effects analysis takes a more proactive approach to identifying, analysing and acting on high-risk clinical processes. Clinical teams can use the approach to identify and address the most vulnerable points in a high-risk process where things could go wrong, but before anything actually does go wrong.
Each participant receives a copy of a 106–page book, Using Failure Mode and Effects Analysis to Improve Patient Safety, that includes principles, step-by-step guidance and examples, and a Failure Mode and Effects Analysis Workbook to record practical work done in the workshop.
Certificates of participation in the workshop are provided.
WHAT PEOPLE SAY ABOUT THIS WORKSHOP
‘This is a useful tool to improve the organization's risk management process.’
‘It showed that the issues you might think would be most important
for failure modes are not necessarily those that score highly
and that a structured method of analysis is valuable.’
‘Gives an excellent framework, found this a useful use of my time.’
PATIENT SAFETY
WORKSHOP
ASSESSING AND MANAGING RISK
Who should attend
The workshop is for healthcare professional staff with responsibility for leading and for participating in decision-making about risk assessment and management in their healthcare services.
What you learn
Clinical leaders and managers of clinical services need to identify and act on risks to their services. However, many risk assessments of clinical services miss out substantial risks or confuse an ongoing issue that is affecting the service with a future risk. Actions on risks sometimes are limited to continuous reporting, and ongoing issues and risks are not always escalated in a healthcare organization when and to whom they should be.
This workshop is intended to open up thinking about issues and risks in a healthcare setting and give step-by-step practical advice on how to describe an issue or a risk properly and how to make appropriate and effective decisions about action on issues and risks.
Each participant receives an 84–page book, Assessing and Managing Risk in Healthcare Settings and an Assessing and Managing Risk Workbook that structures the work carried out in the workshop.
Certificates of participation in the workshop are provided.
The workshop is Certified as conforming to Continuing Professional Development (CPD) requirements in the UK by The CPD Certification Service.
WHAT PEOPLE SAY ABOUT THIS WORKSHOP
‘Excellent, detailed resource materials. I particularly liked the elegant way risk management
was broken down for ease of understanding.’
‘Very informative session, wealth of knowledge from the presenter and passion of the subject was evident.’
‘Would recommend to my colleagues, very worthwhile, lots of knowledge
acquired and practical methods explained well.’
‘Well presented. Adequate resources. Good materials supplied, reinforced learning activities.’
PATIENT SAFETY
WORKSHOP
HOW TO TEACH ASSESSING
AND MANAGING RISK
Who should attend
The workshop is for staff who are expected to teach risk assessment and management in their healthcare organizations. Patient safety, risk, and clinical governance managers and staff also will benefit from participation in the workshop.
What you learn
Healthcare organizations have risk assessment and management systems in place, including provision for risk registers for services in the organization. However, not all clinical leaders and service managers know the most effective ways to assess and manage risk in their services. Important risks can be missed, ongoing issues can be confused with risks, and consequences of risks are sometimes not described sufficiently to enable sound decision-making.
This workshop helps local leaders to teach assessing and managing risk in their own organizations in order to provide more direct support to clinical leads and service managers. The workshop is about what it takes from a teaching perspective to have learners that are successful in carrying out new risk-related processes and practices. Behavioural learning objectives, learner needs analysis, giving clear demonstrations, helping learners through practice based on a workplace situation, and reflections on learning all are covered in this workshop in detail. Practical points such as arranging for teaching sessions, evaluating their success and acting on evaluation feedback also are included.
Each participant receives a 116–page book, How to Teach Assessing and Managing Risk.
Certificates of participation in the workshop are provided.
WHAT PEOPLE SAY ABOUT THIS WORKSHOP
‘Very good training, well organized materials and information thoroughly explained.’
‘Very informative and well-constructed workshop.’
‘Workshop materials are extremely helpful, good quality. Very good workshop leader.’