Preventive and supportive interventions to prevent and minimise the impact of adverse events will be considered at and across the different levels of the health system:
- at the macro level (legislative, regulatory, professional associations, trade unions, occupational health and safety),
- at the meso level (at the level of healthcare service providers)
- at the micro level (at the level of patient care involving frontline healthcare professionals, carers and patients)
This study unit is intended to give the knowledge and skill to health care professionals and managers working at the different levels of health and social care to empower them to prevent adverse events and emergencies and to be knowledgeable and skilled on how to deal with them when they happen.
This study unit is also intended to give knowledge to professionals who support healthcare workers after an adverse event including Human Resources and Occupational Health and Safety Managers, Psychologists, Lawyers.
This study unit is aimed to incorporate different aspects relevant to the preventing and dealing with adverse events including corrective and preventive actions, building resources and infrastructure required such as employee support programmes, psychological safety and support, occupational health and safety, legal framework, governance structures. The unit will consider all the levels of the healthcare ecosystem and the need for an integrated approach.
This study unit should cover knowledge as well as emphasise the skills and behavioural aspects needed in practice.
Topics to consider include the following:
Skills supporting the safety culture in healthcare
-communication, CANDOR
-leadership
-teamwork across professions and with management
-interprofessional training,
-speaking up about mistakes
- impact of safety culture on practice, avoiding defensive practice
-healthcare worker stigma, fear and shame to speak up, invincible attitude, failure culture, learning from experience
-emotional impact of errors, managing emotions
-caring for self, coping behaviours,
-occupational disease / sensitivity to mental health issues
-dealing with aggressive and abusive/disrespectful behaviours
The ‘victims phenomena’
-the first, second and third victims phenomena
-the victims phenomena in association / as an extension of patient safety, professional safety and organisational safety
-second victims as an occupational disease
-perspectives of the ‘victims’ phenomenon by different stakeholders
-Eurobarometer, measurement of citizens perceptions
Safety culture
-patient safety culture, the patient safety experience
-theoretical framework and factors constituting patient safety culture
-tools for measurement and monitoring of patient safety culture and safety experience
-safety culture within healthcare organisations
-learning from mistakes and near misses
-safety culture across the healthcare ecosystem
-healthcare professional safety and psychological safety
-just culture, blame free-culture, safe culture
Governance across the healthcare ecosystem
-adverse events reporting and learning from adverse events
-factors affecting adverse events reporting
-quality management, continuous improvement at the organisational level; monitoring and evaluation
-the learning organisation
-organisational culture, public and private organisaitons, ‘political’ impact / pressure
-the impact of just culture on patient safety and safety of different stakeholders
-corrective and preventive actions within healthcare organisations
-licensing / accreditation of healthcare services and organisations
-monitoring of health care outputs at the organisational level
-monitoring and evaluation of outcomes at the national level
-regulation of healthcare professionals
The legal and ethical frameworks for safety within the healthcare ecosystem
-ethical aspects related to stakeholder safety at the different healthcare levels
-confidentiality and anonymity
-mistakes, honest mistakes, intentional / unintentional mistakes, dealing with mistakes, unanticipated events
-liability, tort and litigation, paying for errors
-legislation on patient safety and second victims
-disclosure and protection of healthcare professionals
-disclosure to patients and its impact, defensive approaches
-use of adverse events for legal purposes
-conflicting interests of stakeholders and protection of stakeholders
-anonymisation of adverse events reports
-compensation systems / legislation
-occupational health and safety legislation in healthcare
-professional indemnity and insurance
Institutional support initiatives and intervention programs
-second victim support programs for healthcare workers involved in -patient safety incidents and peer support programs
-employee support initiatives, employee safety programs,
-burnout of healthcare professionals and sustainability of healthcare systems
-creating awareness, development, resources and design, implementation, evaluation, sustainability
-learning from institutional and peer support programs in other countries e.g. RISE, MISE, PSU (Germany)
-role of professional associations,
-role and impact of trade unions
- protection of the initiative through the legal framework
-learning from safety initiatives in other areas such as aviation
- escalation of support systems: peer support, crisis intervention,
Dealing and coping with situations of adverse events
-possibility of working in simulation centres
-use of case studies from practice
-addressing adverse events within the hospital environment
-training in a safe environment
-seeking, receiving and accepting emotional support, coping strategies
-giving and receiving peer support
-emotional first aid training
Study-Unit Aims:
- To provide knowledge of the impact of adverse events on patients, healthcare workers, health provider organisations and the wider ecosystem
- To provide knowledge of factors affecting the victims phenomenon including national legislation and regulation, patient safety culture, organisational culture across the healthcare ecosystem
- To provide knowledge and develop skills for the development and application of different approaches to prevent and tackle adverse events at the macro, meso and micro level which support safety of the different stakeholders across the ecosystem
- To nurture skill and behaviour which support the management and dealing with adverse events and enforces the adoption of a just culture across the ecosystem
- To provide knowledge and develop skills to deal with legal implications related to adverse events
- To provide knowledge and teach skill and behaviour for the stakeholders to act ethically
Learning Outcomes:
1.
Knowledge & Understanding:By the end of the study-unit the student will be able to:
- implement practice which secures patient safety,
- predict and identify risks and incident causes and impacts
- design for emergency preparedness and corrective and preventive action
- apply corrective and preventive actions to minimize the impact from adverse events
- classify and explain the concepts of first, second and third victims and relationships between them
- classify adverse events, mistakes and near-misses and variables / factors concerned
- identify the consequences of adverse events in patients, significant others, healthcare professionals, healthcare management and organisations and teams
- categorise and analyse different cultural and legal contexts and factors: safety culture, just culture, tort, litigation, approach for dealing with mistakes
- roleplay, appraise and implement potential interventions to support patients and significant others,
- roleplay interventions to support healthcare workers when they are impacted by adverse events, crises and burn out
- appraise and critique factors that help health organisations to maintain a safety climate and avoid medical errors
- demonstrate cultural differences in the interpretation of meaning of errors and how to deal with them in different countries and inter-profesionallly
- apply the correct attitude and behaviour when dealing with all stakeholders including patients and their relatives after an adverse event
- appraise the relevance of the legal framework on safety and practice
- practice psychological safety and demonstrate ability to seek help
- implement occupational health and safety policies
- describe and discuss professional insurance and indemnity, professional code of practice and code of ethics
- demonstrate ability to deal with adverse events considering the perspective of the different stakeholders across the ecosystem
2.
Skills:By the end of the study-unit the student will be able to:
- implement practice which secures patient safety,
- predict and identify risks and incident causes and impacts
- design for emergency preparedness and corrective and preventive action
- apply corrective and preventive actions to minimize the impact from adverse events
- classify and explain the concepts of first, second and third victims and relationships between them
- classify adverse events, mistakes and near-misses and variables / factors concerned
- identify the consequences of adverse events in patients, significant others, healthcare professionals, healthcare management and organisations and teams
- categorise and analyse different cultural and legal contexts and factors: safety culture, just culture, tort, litigation, approach for dealing with mistakes
- roleplay, appraise and implement potential interventions to support patients and significant others,
- roleplay interventions to support healthcare workers when they are impacted by adverse events, crises and burn out
- appraise and critique factors that help health organisations to maintain a safety climate and avoid medical errors
- demonstrate cultural differences in the interpretation of meaning of errors and how to deal with them in different countries and inter-profesionallly
- apply the correct attitude and behaviour when dealing with all stakeholders including patients and their relatives after an adverse event
- appraise the relevance of the legal framework on safety and practice
- practice psychological safety and demonstrate ability to seek help
- implement occupational health and safety policies
- describe and discuss professional insurance and indemnity, professional code of practice and code of ethics
- demonstrate ability to deal with adverse events considering the perspective of the different stakeholders across the ecosystem
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