Module Guide for: A Systems Approach to Patient Safety

Dates of module: 11 – 12 November and 1 – 3 December 2009

Level of module: M Level

Module leader: Dr. Mark-Alexander Sujan

Email address: m-a.sujan@warwick.ac.uk

Contents

Module Specification 1

Aims of the module 2

Learning Outcomes 2

Content 2

Timetable 3

Teaching Faculty 5

Assessment 6

Assessment Criteria 7

Structure of Assignment 13

Reading Suggestions 14

Appendix - Request for Extension Form 16

Module Specification

Credit value: 20 CATS Credits at M level

Pre requisites: None

Directed learning: 30 hours

Self directed learning: 120-150 hours (depending on number of CATS credits being sought)

Teaching learning methods: This will include a mix of lectures and seminars

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Aims of the module:

The module will introduce students to patient safety concepts by approaching the topic from a systems perspective and by embedding it into a wider clinical systems improvement and risk management framework.

Learning Outcomes:

By the end of the module the student should be able to:

Describe patient safety as a scientific discipline Demonstrate a systematic understanding of the ways in which processes

relating to patient safety rely on human, technical and organisational resources

Identify and evaluate the underlying organisational factors that may contribute to adverse events

Critically appraise research findings relating to the identification of common adverse events in healthcare settings and evidence from research and evaluation relating to the selection of effective means of mitigation

Embed patient safety interventions in the wider context of clinical systems improvement and risk management

Compare and contrast methodologies and practices across disciplinary borders and learn from other specialities and contexts

Content

Day One: Patient Safety as a scientific discipline

Day Two: Systems Perspective

Day Three: Patient Safety Risk Management

Day Four: Clinical Systems Improvement

Day Five: Managing & Leading Improvement in Patient Safety

Debriefing session

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A System Approach to Patient Safety – Timetable

11th November: Day 1 – Patient Safety as a Scientific Discipline 12th November: Day 2 – Systems Perspective

09:15 – 09:30 Coffee, CPD area, Medical School Building Coffee, CPD area, Medical School Building09:30 – 11:00 Introduction to patient safety

Learning Approach Introduction to the course & objectives Overview: Framework for Patient Safety Extent of the problem, studies of adverse events, examples Clinician’s journey in patient safety

Matthew Cooke / Mark-Alexander Sujan

Human Error

Rasmussen’s SRK Framework Reason’s GEMS classification Beyond human error

Mark-Alexander Sujan

11:00 – 11:20 Coffee Coffee11:20 – 12:50 Group work: The Wrong Patient

Making sense of an adverse event Discussion of factors influencing the safety of patients

Mark-Alexander Sujan

Organisational Failures

Video: Kegworth accident Organisational model of accidents Assessing the causal context

Mark-Alexander Sujan

12:50 – 13:50 Lunch Lunch13:50 – 14:50 Video: A routine operation

What can be achieved?

Clinical examples Participants’ examples

Matthew Cooke

Safety Culture

Video: Piper Alpha accident Safety culture & safety climate Accountability vs. the need to learn

Mark-Alexander Sujan14:50 – 15:10 Tea Tea15:10 – 16:30 Common Study Methods & Approaches

Studies investigating the extent of harm Studies investigating the mechanisms of failure Studies investigating improvements

Matthew Cooke / Mark-Alexander Sujan

Learning Organisation

Investigating adverse events

Incident reporting Risk Monitoring

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Course Assessment Explanation Mark-Alexander Sujan

1st December: Day 3 - Patient Safety Risk Management / Reliability & Resilience

2nd December: Day 4 – Clinical Systems Improvement & Measurement

3rd December: Day 5 – Leadership

09:15 – 09:30 Coffee, CPD area, Medical School Building Coffee, CPD area, Medical School Building

Coffee, CPD area, Medical School Building

09:30 – 11:00 Introduction to Patient Safety Risk Management

Hazards, safety, risk Principles of safety risk management High Reliability Organisations

Mark-Alexander Sujan

Clinical Systems Improvement in Practice

Ian Cunliffe

Managing & Leading Patient Safety Interventions

Matthew Cooke

11:00 – 11:20 Coffee Coffee Coffee11:20 – 12:50 Methods & Approaches

Process Mapping & Task Analysis Failure Mode and Effects Analysis Barrier Design

Cathy Ingram / Mark-Alexander Sujan

Linking Improvement and Safety

Matthew Cooke

Leadership: Theory & Practice

Case Study – SBAR for handovers

Hugh Flanagan12:50 – 13:50 Lunch Lunch Lunch13:50 – 14:10 Case Study – WHO Checklist

Matthew Cooke

Case Study – Bare below the elbows

Matthew Cooke

Course Evaluation

Andrew Taylor

14:10 – 14:50 Case Study: Enhancing the reliability of prescribing on admission

Cathy Ingram

Evidence of Improving Safety

Matthew Cooke

Wrap-up

Feedback

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Nick Rich Assignments Mark-

Alexander Sujan

14:50 – 15:20 Tea Tea Close 15:20 – 16:30 Group work: Enhancing the reliability of a clinical

process Matthew Cooke / Mark-Alexander Sujan

Evidence of Improving Safety

Matthew Cooke/ Nick Rich

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A Systems Approach to Patient Safety

Module Leader: Dr Mark-Alexander Sujan, Warwick Medical School

Teaching Faculty

Dr Mark-Alexander SujanAssistant Professor, Warwick Medical School

Mark-Alexander Sujan is a human factors and safety engineer. He has investigated safety, resilience and human factors aspects in different domains, such as railways, aviation and healthcare. He joined Warwick Medical School as Assistant Professor (RCUK Fellow) in 2006. He has been teaching on the NHS Institute Leading Improvement in Patient Safety (LIPS) core module, their Reliability in Healthcare advanced module as well as their Patient Safety Managers course. He continues to maintain links to other industries through consultancy or teaching activities, such as the EUROCONTROL General Human Factors Training course.

E-mail address: m-a.sujan@warwick.ac.uk

Prof Matthew Cooke, PhD MB ChB FRCS(Ed) FCEM DipIMCProfessor of Emergency Care, Warwick Medical School.

Professor Matthew Cooke is Professor of Emergency Medicine at Warwick Medical School and Consultant in Emergency Medicine at Heart of England NHS Trust. He is a Senior Fellow in the NHS Improvement Faculty for Patient Safety and Quality Improvement

He leads the Warwick Clinical Systems Improvement Group. Until August 2007 he was the emergency medicine advisor to the Dept of Health, where he was one of the authors of government strategy Reforming Emergency Care and was the clinical lead for its implementation, leading to all English emergency departments having 98% of patients discharged/admitted to a ward within 4 hours of arrival. During this time emergency departments and ambulance services underwent massive modernisation. In 2007-2008 he was the regional clinical lead for the Darzi Review (the national review of the NHS). Professor Cooke speaks and advises internationally on emergency care systems as well as having advised the National Audit Office, Healthcare Commission and the Prime Ministers Delivery Unit.

E-mail address: M.W.Cooke@warwick.ac.uk

Ian CunliffeMedical Director, Heart of England Foundation Trust

Ian Cunliffe is Medical Director at Heart of England Foundation Trust and has initiated and overseen many successful improvement projects in his Trust.

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Assessment:

Critical reflection on a practical patient safety problem based on your organisation or one with which you are familiar. The assignment is designed to encourage you to identify, to read and to reflect upon the relevant patient safety literature with a view to the problem you are addressing.

The essay / course work should be approximately 4000 words. You should:

Describe the problem and supply evidence thereof Identify and refer where relevant to existing literature Reflect on how the problem is embedded within the wider systems, clinical systems

improvement and risk management context Complete your report with conclusions and recommendations Enclose with your report an executive summary of 200-400 words outlining the contents

of the report

To be submitted online by: 4th March 2010

Any extension to this deadline must be negotiated with the module leader and have the approval of the course director. This should be done by completing the Request for Extension Form (see Appendices of this Module guide).

Coursework Submission Guidance

You will be required to submit your assignment on line using the Turnitin system by 4 th March 2010. You will be given further instructions on how to do this.

Support for your assignment

Students are encouraged to exchange contact details and provide each other support in reading and critiquing assignment ideas.

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Warwick Medical School

NEW MASTERS LEVEL ASSESSMENT CRITERIA FROM SEPTEMBER 2007

CRITERIA A+80% plus A 70 – 79% B 60 – 69% C 50-59% D 40 – 49% E 39% and below

KNOWLEDGE AND UNDERSTANDING

1. Evidence that a wide range of high

quality literature has been accessed e.g.

Credible sources – peer reviewed, professional/academic texts, websites, DOH directives.

Original work accessed whenever possible

Contemporary - with exception of seminal work

2. Discussion is supported by relevant literature/research e.g.

Claims are substantiated

80% plus mark is awarded when work satisfies all of the ‘A’ criteria in each section to an exceptional level demonstrating mastery of complex and specialised knowledge and is worthy of dissemination to a wider audience.

There is excellent evidence of widespread reading from a variety of sources. Excellent use of literature and research, appropriately integrated into the assessment to demonstrate exceptional understanding of the key issues.

There is very good evidence of background reading and reference material is used appropriately to support the discussion. Very good grasp of the relevant material demonstrating a good understanding of the key issues.

There is evidence of relevant background reading and this is generally used in a suitable way to substantiate the assignment content. There is a competent level of understanding of the key issues.

Whilst there is some evidence of background reading this is not of a quality consistent with this level of study. There is limited understanding of the key issues.

Little evidence that suitable background material has been accessed and poor understanding of the key issues.

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Literature/reference material is appropriate and clearly linked to the assignment topic.

Integration/paraphrasing/ summarising of research findings rather than overuse of direct quotations

3. A coherent and thorough overview of theoretical concepts is presented demonstrating understanding of the key issues e.g.

Aims of the assignment are clearly stated

The assignment addresses the question asked/guidelines

The key issues relating to the assignment topic are identified

Assignment methodology is clear and appropriate e.g. search strategy for literature

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CRITERIA A+80% plus A 70 – 79% B 60 – 69% C 50-59% D 40 – 49% E 39% and below

ANALYSIS AND EVALUATION

1. Excellent evidence of critical analysis e.g.

Identifying and challenging assumptions An awareness of the importance of

context in creating meaning

2. Exceptional critical evaluation of the strengths and weaknesses of cited research/literature e.g.

Does not take evidence on ‘face value’ An awareness of the limitations of

research or literature e.g. 1. Methodology2. Validity and reliability3. Age 4. Comparison of results of

studies5. Generalisability

3. Excellent evidence of reflection (as appropriate) e.g.

Use of a structured model of reflection (as appropriate e.g. in assignment briefs for which reflection is a core requirement)

An analysis/awareness of personal values, ideas, assumptions and actions.

Identification of alternative

80% plus mark is awarded when work satisfies all of the ‘A’ criteria in each section to an exceptional level demonstrating mastery of complex and specialised knowledge and is worthy of dissemination to a wider audience.

There is excellent evidence of critical analysis and reflection accompanied by a profound appraisal of the literature and evaluation of theoretical concepts.

The material is managed in a highly creative way demonstrating evidence of originality of thought. Excellent evidence of synthesis of ideas and key concepts, articulately expressed.

There is very good evidence of critical analysis and reflection with evaluation of the literature/ theoretical concepts. The material is managed in a creative way with expression of some original thought. There is a good level of synthesis of ideas and key concepts.

Whilst there is evidence of critical analysis and reflection some issues required further exploration. There is a competent level of evaluation of the literature and theoretical concepts. There is evidence of originality of thought, although some areas are underdeveloped and managed in an unimaginative way. There is a competent level of synthesis of ideas and key concepts.

There is very limited evidence of critical analysis and reflection and much of the writing is descriptive. Evaluation of the literature and key concepts is scarce and there is a lack of originality in the way the material is handled. There is poor evidence of synthesis.

Little or no evidence of critical analysis or reflection and the discussion is entirely descriptive.

There is very poor evaluation of the literature and theoretical concepts and

no credible judgements are formed.

No evidence of original and innovative thought or creative use of concepts.

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action/solutions

ANALYSIS AND EVALUATION continued

4. Uses data selectively to construct a logical discussion e.g. Clear relationship between data (i.e.

research/literature) and topic under discussion

Doesn’t ‘over reference’ 5. Profound and credible judgements are

made/formed e.g. The judgements made are the logical

conclusion of the analysis/discussion

6. Excellent evidence of synthesis of ideas/concepts e.g.

Various components of the topic are combined to produce a newly constructed whole i.e. specific and related literature/concepts

Creative use of concepts. Imagining and exploring alternatives

7. Excellent evidence of original and creative thought/perspectives e.g.

The topic is approached or discussed in an innovative way

Imaginative but realistic solutions to problems are suggested

There is evidence of unique perspectives of a problem/evidence

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CRITERIA A+80% plus A 70 – 79% B 60 – 69% C 50-59% D 40 – 49% E 39% and below

APPLICATION

1. Credible links between theory and professional practice are demonstrated.

Evidence of the interpretation of theoretical perspectives through the use of clinical examples.

Realistic recommendations for professional practice are suggested

2. Evidence is excellently evaluated and applied to professional practice e.g.

Demonstrates how the material presented contributes to professional practice

80% plus mark is awarded when work satisfies all of the ‘A’ criteria in each section to an exceptional level demonstrating mastery of complex and specialised knowledge and is worthy of dissemination to a wider audience

Credible links between theory and professional practice are demonstrated to an exceptional level. There is excellent appraisal of evidence which supports the application of theory to practice.

There is good evidence of credible and relevant links between theory and professional practice. The evaluation of the evidence is of a good standard and supports the application of theory to practice.

Competent links between theory and professional practice are made although some areas could have been developed further to demonstrate evaluation of the evidence and the application of theory to practice.

There are some attempts to link theory to professional practice but these are limited and, in some cases, unrealistic or inappropriate. The evaluation of evidence is minimal.

Irrelevant or no links are made between theory and professional practice. Evidence is not evaluated.

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COMMUNICATION

1.The assessment guidelines have been rigorously interpreted and followed e.g.

The module guidelines have been followed e.g. demonstrate the module learning outcomes.

2. Coherent and logical structure e.g.

Structure is appropriate for the assignment topic e.g. an audit would use appropriate methodology

3. Correctly and consistently formatted references and citations e.g.

An approved method of referencing has been used both within the assignment text and in the reference list

4. Writing is articulate with excellent clarity, and appropriate for the audience it is written for e.g.

An information leaflet would be written in appropriate language for patients

Appropriate use of technical language Correct spelling, grammar and syntax. Variety in the way information is

presented

5. Word limit is adhered to The set word limit is used give or take

80% plus mark is awarded when work satisfies all of the ‘A’ criteria in each section to an exceptional level demonstrating mastery of complex and specialised knowledge and is worthy of dissemination to a wider audience.

Excellent interpretation of assessment criteria. Writing is highly articulate and there is a logical, coherent structure. Referencing technique is excellent. Word limit is adhered to.

Very good interpretation of the assessment criteria. Generally the writing is articulate and there is a logical flow of information expressed through a clear assignment structure. Work is accurately referenced. Word limit is adhered to.

A competent interpretation of the assessment guidelines. There are clear attempts to provide a logical structure but there are some inconsistencies in the approach used. Referencing technique is satisfactory. Word limit is adhered to.

There are attempts to interpret the assessment guidelines but some of these are flawed. The assignment lacks a clear and logical structure and due to poor writing skills, ideas and concepts are not adequately expressed. Does not maintain an accurate referencing technique. Unsatisfactory length.

The assignment demonstrates little relevance to the assessment guidelines or the area of study. It lacks structure and there is poor use of language including several and recurrent grammatical and syntax errors. The expression of meaning is very weak and there are numerous referencing errors. Unsatisfactory length.

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Structure

Your assignment should be structured in a manner appropriate to the nature of the study undertaken. A version of the IMRAD (Introduction, Methods, Results and Discussion) format is presented here for guidance. Note that this format is generally associated with empirical studies but is also appropriate for studies employing literature review as the main research method with the modifications shown in italics.

Introduction What the reader can expect to find in the dissertationWhy this particular issue was chosen

Background A critical review of the literature (and, where appropriate, ‘grey’ literature, i.e. material with limited circulation) to include:

why the issue is important how the issue is currently approached and analysed what is already known what is the theoretical basis for this study

Research question Stating the questionsSetting the boundaries of the project

Methodology Description and justification of the chosen methodsSummary of literature search on methods

Method Methods used for data collection[or for selection/exclusion of literature and for data extraction]Methods used to analyse data[or to synthesise data extracted from the literature]

Results Present the resultsAim to write clearly, concisely and unambiguouslyClearly label relevant tables, graphs and line drawings

Discussion Interpret and explain what the results tell youWhat points of particular interest emergeHow far does this support or question the literatureHow does it answer your research questionsIdentify the limitations of your work

Conclusions Summarise the findingsState your conclusions and why you have reached themGive suggestions for areas of future research and recommendations for implementations

References The Harvard system is preferred, but the Vancouver (Numeric) system is also acceptable. Only one system should be used throughout the document.

Appendices The main body of the text should be capable of being read and understood alone. Material in the appendices should not need to be read by the examiners, but is provided for completeness and for information, if required.

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Reading suggestions:

Pre-reading:

Students are advised to engage with Charles Vincent’s very readable short overview of patient safety: C. Vincent. Patient Safety, Churchill Livingstone, 2005

For Leadership and Safety: http://www.ihi.org/IHI/Results/WhitePapers/LeadershipGuidetoPatientSafetyWhitePaper.htm

Measuring safety: http://www.cpssq.org/Publications/Resources/Resources%20information/PSI%20report%20v2.pdf - but just read the executive summary!

Day Topic ReferencesDay 1 High Profile Cases K. Walsche & N. Offen. A very public failure: lessons

for quality improvement in healthcare organisations from the Bristol Royal Infirmary. QSHC 2001; 10; 250-256Investigation into outbreaks of C.diff at Maidstone & Tunbridge Wells NHS Trust, Healthcare Commission, 2007

Extent of the problemC. Vincent. Patient Safety (Chapter 1 – 3), Churchill Livingstone, 2005L.T. Kohn et al. To err is human: building a safer health system (Chapter 2). National Academy Press, 2000C. Vincent et al. Adverse events in British hospitals: preliminary retrospective record review. BMJ 2001; 322: 517-519

Clinician’s journey in patient safety

DH. An Organisation with a Memory. 2000 DH. Safety First: a report for patients, clinicians and healthcare managers. 2006

Case study: The Wrong Patient

M.R. Chassin & L.C. Becher. The Wrong Patient. Ann. Intern. Med. 2002;136:826-833

Vision of what can be achieved

J. Whittington et al. Reducing Hospital Mortality Rates. IHI, 2005

Studies of adverse events See above: Vincent/Kohn et al./Vincent et alK. Taxis & N. Barber. Causes of intravenous medication errors: an ethnographic study. QSHC, 2003; 12:343-347D.W. Bates et al. Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA, 1995; 274:29-34J.P. Burke. Infection Control – A problem for patient safety. NEJM, 2003; 348:651-656

Day 2 Human Error J. Reason. Human Error. Cambridge University Press, 1990

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Organisational Failures J. Reason. Human Error: Models and Management. BMJ 320:768-770, 2000J. Reason. Managing the risk of organisational accidents. Ashgate, 1997C. Perrow. Normal Accidents. Basic Books, 1984

Safety Culture R. Flin. Measuring Safety Culture in Healthcare: A Case for Accurate Diagnosis. Safety Science 45:653-667, 2007NPSA 7 Steps to Patient Safety, 2004NPSA Manchester Patient Safety FrameworkS. Dekker. Just Culture: Balancing Accountability and Safety, Ashgate 2008

Day 3 High Reliability Organisations

K.E. Weick & K.M. Sutcliffe (2007). Managing The Unexpected (2nd Ed.), Josey-Bass (Readable presentation of characteristics of High Reliability Organisations)

Introduction to Reliability in Healthcare

E.A. McGlynn et al., The Quality of Care Delivered to Adults in the United States. New England Journal of Medicine, 2003; 348:2635-45R. Amalberti et al., Violations and migrations in healthcare: a framework for understanding and management, QSHC, 2006; 15:i66-i71R. Amalberti et al., 5 System Barriers to Achieving Ultrasafe Healthcare, Ann. Intern. Med., 2006; 152:756-764M. Landau, Redundancy, Rationality and the Problem of Duplication and Overlap, Public Administration Review, July/August 1969; 346-358T. Nolan et al., Improving the Reliability of Healthcare, IHI White Paper, 2004

Management of risk in safety critical industries

J. Reason. Managing the risk of organisational accidents. Ashgate, 1997D Embrey et al Guidelines for Reducing Human Error in Process Safety. Wiley Center for Chemical Process Safety : New York 1994

Learning Organisation DH, An Organisation with a Memory, 2000Day 4 Clinical Systems

ImprovementDay 5 Leadership

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Appendix

1. Coursework Request for Extension form

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Assignment Extension Request Form

(To be submitted at least TWO weeks prior to the day the assignment is due. Please see General Handbook on late submissions)

Student Name: __________________________________________________

Name of Module: A Systems Approach to Patient Safety

Date Coursework Due: 4th March 2010

I am unable to submit my course assignment by the due date for the following reasons:

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I am writing to request that I be granted an extension and I propose to submit the work by:

Date: ____________________________

Signed: ____________________________

Please send to: Rose Bradley, Course Co-ordinator, Institute of Clinical Education, Studies, Warwick Medical School, University of Warwick, Coventry CV4 7AL

-----------------------------------------------------------------------------------------------------------------MODULE: A Systems Approach to Patient Safety

Coursework Extension Acknowledgement

To:_________________________________________________________

From:_________________________________________________________

I confirm that your request for an extension has been approved.

Your new submission date is: ________________

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