An Introduction to Human Factors and Patient Safety

Section 1: Clinical Error

9 Topics

What are Human Factors?

Understanding Clinical Error

Improving Patient Safety

Case Study Activity – Causal Factors

Elaine Bromiley Case

Swiss Cheese Model

The Shell Model

The Bow Tie Model

Section 2: Introduction to Cognition

9 Topics

Introduction to Cognition

Attention Mechanisms

Memory Experiment

Pattern Recognition

High Risk Situations

Factors That Make Error More Likely

Apter’s Reversal Theory

Section 3: Human Behaviours

11 Topics

Communication Case Study

Communication Techniques

Communication PACE

Decision Making

Leadership & Management:

Teamwork & Co-operation: Question 1

Teamwork & Co-operation: Question 2

Teamwork & Co-operation: Question 3

Teamwork & Co-operation: Personalities

An introduction to Human Factors and Patient Safety – Post Test

Communication Case Study

An Introduction to Human Factors and Patient Safety Section 3: Human Behaviours Communication Case Study

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1. Question
Val an anaesthetist gave a patient 2g paracetamol at end of a case, then noticed that another anaesthetist had given 2g earlier, after investigation Val discovered that this had been recorded on the patient's chart but that the chart was not handed over.

Where has the communication process failed in this case?
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