Technical Notes:
You will need the Quicktime plugin to view content in this course. You will also need to enable ActiveX within Internet Explorer. To enable ActiveX, do the following:
Go to 'Start' > 'Programs' > 'Internet Explorer'
In Internet Explorer's menu, go to 'Tools' > 'Internet Options' >
'Security' >
'Custom Level' > 'Enable Run Active X controls and plug-ins'
Hit 'Apply' or 'OK' and restart your browser. (these directions are based on the most common install, and may not work for all cases).
PEXiS 1 Course Objectives, Content, and CEU
Instructions:
1. Understand what the "New Look" at patient safety is and why
it
is important in contrast to the tendency to prematurely and
insufficiently use the label "human error". Thus, in this course
students will learn the following concepts and why they are important in
order to understand the nature of complex systems and how they can
sometimes failure:
- multiple contributing factors in complex systems, each necessary, but only jointly sufficient
- complexity from coupling, laws of requisite variety, trade-offs, and double binds
- feedback and recovery from incipient failures
- drift towards failure
- hindsight bias
- bounded rationality
- the perceptual cycle and the effect of knowledge, mindset and goals
- organizational factors
- sharp-end/blunt-end failures
- cultures of safety
- side effects of change
- how people sustain success in work
2. Develop analytical skills through studying multiple, varied accident investigations:
- Students will be given descriptions of real cases of realistic detail and complexity to recognize the relevance of the concepts covered in the course and to develop practical analytical skills so that contributions towards failure can be identified
- These cases will come from diverse domains such as healthcare, space missions, public transportation and military operations, in order to demonstrate the range of application for the concepts covered, but also how lessons can be learned from converging evidence across domains
3. Unify the knowledge gained from studying the general concepts and specific cases, with the practical skills and apply what has been learned to their own work environment and reflect on how it is relevant, and how they should use this new knowledge to improve safety in that context. Thus, students will:
- Study the nine steps to move forward on patient safety
- Write a reflective essay on what they have learned and how it applies to their work context
Course instructions
This course uses stories about disasters to teach concepts about predictable sources of systems failures within healthcare as well as in other complex industries as an introduction to examining the role of human factors in patient safety.
Error analysis historically has focused on identifying the single "cause" of an incident. The ‘New Look’ proposes that accidents in complex systems occur as a result of multiple contributing failures, each necessary, none alone sufficient. Inherent in this approach is the concept that all complex systems contain latent failures.
A note on the course pedagogical structure:
PEXiS 1: Behind the Label ‘Human Error’ is an educational program designed to improve patient safety by raising understanding of human performance elements implicit in accidents. Each submodule contains a combination of expositions, reflections, walkthroughs, and participatory activities ("doing"), based on the discovery learning model of instructional design. We encourage you to make multiple loops through the exercises, and to review the sample student answers where provided.