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E-SHARE500_1

Safety investigation in healthcare

This is the study programme for 2019/2020. It is subject to change.


One of the most fundamental aspects of safety in healthcare is to learn from adverse events to improve future healthcare services. Every year a large number of patient across the world are harmed by adverse events due to for example late diagnosis, wrong diagnosis, wrong treatment, technical failure, medication errors and infections. In order to learn from these events, safety investigation is key. Investigating and learning from serious adverse events is a complex process that confronts many challenges. This course is about safety investigations in healthcare and how these can be understood and approached. The aim of the course is to give students the knowledge, skills, and analytical capacity to understand important conditions for achieving high quality safety investigations in healthcare.

Learning outcome

Upon completion of this course, the students are expected to have the following knowledge, skills, and general competence:
Knowledge:
  • About the foundation for different types of safety investigations
  • About existing accident models and theories explaining causality
  • About principles, practices and processes of safety investigations
  • About safety investigation methods in healthcare and other industries
  • About how different stakeholders' (e.g. patients, next of kin, healthcare professionals, managers, regulators) perspectives and experiences can be incorporated into safety investigations
  • About strengths and limitations in safety investigations

Skills:
  • To apply accident theories and investigation methods in practice
  • To evaluate scientific publications in safety investigation

General competence:
  • To critically analyze different theoretical, methodological and practical approaches to safety investigations in healthcare.

Contents

The course content is based on recent research into accident and safety investigations in healthcare, but examples from other industries and sectors will be applied when relevant. The course covers the following main topics:
  • Accident models and theoretical foundation for safety investigations
  • Complexity of healthcare systems, technology and people
  • Methods of safety investigations
  • Patient and stakeholder involvement in safety investigations
  • Just culture, safety investigation and organizational learning
  • Simulation in safety investigations

Required prerequisite knowledge

None.

Exam

Weight Duration Marks Aid
Group term paper on selv-selected research problem1/1 Pass - FailAll.
Group term paper on self-selected research problem (5000 words)

Coursework requirements

  • Collaborative group work: presentation on the curriculum applied in safety investigation cases
  • Submitted and approved essay about the research problem for the group assignment exam term paper (maximum 500 words)

Course teacher(s)

Course coordinator
Veslemøy Guise , Cecilie Haraldseid-Driftland , Siri Wiig
Course teacher
Karina Aase , Ove Njå

Method of work

Teaching is based on student-active collaborative learning methods, where both individual and team effort is required. Teaching will extend over three one-day sessions. Student tasks to be completed between sessions.

Open to

EVU students only

Course assessment

There is continuous evaluation of the quality of the teaching and learning experience according to current regulations.

Literature

Literature (Ca 400-500 pages)
L. Behr, K.J. Grit, R.A. Bal & P.B.M. Robben (2015). Framing and re-framing critical incidents in hospitals. Health Risk & Society, 17 (1), 81-97. doi: 10.1080/13698575.2015.1006587
Bouwman R, de Graaff B, De Beurs D, et al. Involving patients and families in the analysis of suicides, suicide attempts, and other sentinel events in mental healthcare: a qualitative study in the Netherlands. Int Jour of Environmental Research and Public Health, 2018;15(6):1104.
Canham, A., Jun, G. T., Waterson, P., & Khalid, S. (2018). Integrating systemic accident analysis into patient safety incident investigation practices. Applied Ergonomics, 72, 1–9. http://doi.org/10.1016/j.apergo.2018.04.012
Carthey, J., de Leval, M. R., & Reason, J. T. (2001). Institutional resilience in healthcare systems. Quality in Health Care, BMJ Quality & Safety;10: 29-32.
Cook R, Rasmussen J. (2005). “Going solid”: a model of system dynamics and consequences for patient safety. BMJ Quality & Safety;14: 130-134.
Dekker, S. (2015). The psychology of accident investigation: epistemological, preventive, moral and existential meaning-making. Theoretical Issues in Ergonomics Science,16, 3, 202-213, http://dx.doi.org/10.1080/1463922X.2014.955554
Diekman, P. et al (2017). Variation and adaptation: learning from success in patient safety-oriented simulation training. Advances in Simulation (2017) 2:21 DOI 10.1186/s41077-017-0054-1 (14s)
Etchegaray JM, Ottosen MJ, Burress L, et al. (2014) Structuring Patient And Family Involvement In Medical Error Event Disclosure And Analysis. Health Affairs;33(1):46-52.
Fitzsimons,B. & Cornwell, J. (2018). What can we learn from patients’ perspectives on the quality and safety of hospital care? BMJ Qual Saf; 27:671–672. doi:10.1136/bmjqs-2018-008106
Filhoa, A.P.G, Junb,G-T., Waterson, P. (2019). Four studies, two methods, one accident – An examination of the reliability and validity of Accimap and STAMP for accident analysis. Safety Science, 113, 310-317. https://doi.org/10.1016/j.ssci.2018.12.002
Hibbert, P. D., Thomas, M., in, A. D. J. F. Q.,et al. (2018). Are root cause analyses recommendations effective and sustainable? An observational study. International Journal for Quality in Health Care, 30, 2, 124–131, http://doi.org/10.1093/intqhc/mzx181
Kellogg, K. M., Hettinger, Z., Shah, M., et al., (2017). Our current approach to root cause analysis: is it contributing to our failure to improve patient safety? BMJ Qual Saf; 26:381-387. http://doi.org/10.1136/bmjqs-2016-005991&domain=pdf&date_stamp=2017-03-21
Kok J, Leistikow I, Bal R. (2018). Patient and family engagement in incident investigations: exploring hospital manager and incident investigators’ experiences and challenges. Journal of Health Services Research & Policy; 23(4):252-261.
LeCoze, J.C. (In press). Vive la diversité! High Reliability Organisation (HRO) and Resilience Engineering (RE). Safety Science Available online 26 April 2016
Leveson, N., Samost, A., Dekker, S., Finkelstein, S., & Raman, J. (2016). A Systems Approach to Analyzing and Preventing Hospital Adverse Events. Journal of Patient Safety, 1-6. http://doi.org/10.1097/PTS.0000000000000263
Liberati, E. G., Peerally, M. F., & Dixon-Woods, M. (2017). Learning from high risk industries may not be straightforward: a qualitative study of the hierarchy of risk controls approach in healthcare. International Journal for Quality in Health Care, 1–5. http://doi.org/10.1093/intqhc/mzx163
Macrae, C., & Stewart, K. (2019). Can we import improvements from industry to healthcare? BMJ, 364, l1039. http://doi.org/10.1136/bmj.l1039
Macrae, C. (2015). The problem with incident reporting. BMJ Quality and Safety, 25(2), 92–99. http://doi.org/10.1136/bmjqs-2015-004405
Macrae, C. (2018). Imitating incidents: how simulation can improve safety investigation and learning from adverse events. Simulation in Healthcare, 13(4):227-232. http://doi.org/10.1097/SIH.0000000000000315
Macrae, C., & Vincent, C. (2014). Learning from failure: the need for independent safety investigation in healthcare. Journal of the Royal Society of Medicine, 107(11), 439–443. http://doi.org/10.1177/0141076814555939
Nicolini, D., Waring1, J., & Mengis2, J. (2011). The challenges of undertaking root cause analysis in health care: A qualitative study. Journal of Health Services Research & Policy, 16(1_suppl), 34–41. http://doi.org/10.1258/jhsrp.2010.010092
Nixon, J., Braithwaite, GR. (2018). What do aircraft accident investigators do and what makes them good at it? Developing a competency framework for investigators using grounded theory. Safety Science, 103, 153-161. http://doi.org/10.1016/j.ssci.2017.11.017
O’Hara JK, Aase K, Waring J, Scaffolding our systems? Patients and families ‘reaching in’ as a source of healthcare resilience. BMJ Quality & Safety 2018;28(1):1-3.
Pidgeon, N., & O’Leary. M. (2000). Man-made disasters: why technology and organizations (sometimes) fail. Safety Science 34 (2000) 15-30 (15s)
Peerally, M. F., Carr, S., Saf, J. W. B. Q., (2017). The problem with root cause analysis. BMJ Qual Saf;26: 417-422. http://doi.org/10.1136/bmjqs-2016
Reason, J. (2000). Human error: models and management. BMJ, 320(7237), 768-771.
Salmon, P. M., Cornelissen, M., & Trotter, M. J. (2012). Systems-based accident analysis methods: A comparison of Accimap, HFACS, and STAMP. Safety Science, 50(4), 1158–1170. http://doi.org/10.1016/j.ssci.2011.11.009
Seys D., et al., (2012). Health Care Professionals as Second Victims after Adverse Events: A Systematic Review. Evaluation & the Health Professions 36(2) 135-162. (28s)
Stanton, N.A.,Salmon, P.M., Rafferty, L.A., Walker, G.H., Baber, C., Jenkins, D.P. (2013). Human Factors Methods: A Practical Guide for Engineering and Design.2nd Edition. Chapter 6 «Human error and accident analysis methods”.
Tamuz, M. and Harrison, M. I. (2006). Improving Patient Safety in Hospitals: Contributions of High‐Reliability Theory and Normal Accident Theory. Health Services Research, 41: 1654-1676. doi:10.1111/j.1475-6773.2006.00570.x
Weick, K. E., & Sutcliffe, K. (2003). Hospitals as cultures of entrapment: A re-analysis of the Bristol Royal Infirmary. California Management Review, 45(2), 73-84. https://doi.org/10.2307/41166166
Wiig, S & Macrae, C. (2018). Introducing national healthcare safety investigation bodies. British Journal of Surgery, Vol,105: 1710–1712.
Wiig, S., Haraldseid-Driftland, C., Tvete Zachrisen, R., Hannisdal, E., & Schibevaag, L. Next of Kin’s Experiences with Involvement in Regulatory Inspections of Adverse Events: A process evaluation (Part I). Journal of patient safety. (Forthcomming).
Wiig, S., Schibevaag, L., Tvete Zachrisen, R., Hannisdal, E., Anderson, J., & Haraldseid-Driftland, C. Regulatory Inspectors’ Expectations and Experiences of Involving Next of Kin in Investigations of Adverse Event - A process evaluation (Part II). Journal of patient safety. (Forthcomming).
Wrigstad, J., Bergström, J., & Gustafson, P. (2017). One event, three investigations: The reproduction of a safety norm. Safety Science, 96, 75–83. http://doi.org/10.1016/j.ssci.2017.03.009
Wu, A. & Steckelberg, R.C. (2012). Medical error, incident investigation and the second victim: doing better but feeling worse. BMJ Qual Saf April 2012 Vol 21 No 4 (4s)

Recommended reading:
Simplicity in Safety Investigations 2017 by Ian Long https://www.amazon.co.uk/dp/113809773X/ref=pe_3187911_189395841_TE_dp_1
Patient Safety: Investigating and Reporting Serious Clinical Incidents Paperback 2017 by Russell https://www.amazon.co.uk/dp/1498781160/ref=pe_3187911_189395841_TE_dp_2
Human Factors Methods and Accident Analysis: Practical Guidance and Case Study Applications by Paul M. Salmon, Neville A. Stanton, et al. Dec 2011 https://www.amazon.co.uk/Human-Factors-Methods-Accident-Analysis/dp/1409405192/ref=sr_1_7?keywords=stanton+human+factors&qid=1563361151&s=books&sr=1-7


This is the study programme for 2019/2020. It is subject to change.

Sist oppdatert: 23.11.2019

History