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AHMC801 – Safety and Quality in Hospital Care

2017 – S2 Day

General Information

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Unit convenor and teaching staff Unit convenor and teaching staff Unit Convenor
John Cartmill
Teaching Assistant
Stephanie Hunt
Credit points Credit points
4
Prerequisites Prerequisites
Admission to DAdvSurg or DAdvMed or MASurg or MAMed or MSurg or MMed or MMedPrac or GradDipSpSurg or GradDipSpMed or GradCertClinLship or MLabQAMgt
Corequisites Corequisites
Co-badged status Co-badged status
Unit description Unit description
Safety and quality are vitally important and ongoing aspects of hospital care. This unit critically examines decision making and error in everyday life and progresses these concepts by focusing on medical errors, how to respond to error, how to discuss error with patients and colleagues, and how to prevent errors from happening again. Discussions also include examining how medical error is reported in the media and potential political and legal responses to error.

Important Academic Dates

Information about important academic dates including deadlines for withdrawing from units are available at http://students.mq.edu.au/student_admin/enrolmentguide/academicdates/

Learning Outcomes

  1. Understand the scope, nature and causes of the most common safety problems
  2. Understand human factors in theory and practice
  3. Understand the nature and elements of well functioning teams in patient care and demonstrate techniques to make a team work
  4. Understand what constitutes a safety culture and how to foster change
  5. Demonstrate capacity to lead, coordinate and participate in quality improvement initiatives
  6. Demonstrate capacity to learn from error, including the RCA Process
  7. Understand the purpose and importance of and demonstrate competence in talking about error with clinicians, managers, patients and families, including open disclosure
  8. Demonstrate an understanding of personal ergonomics and determinants of human performance
  9. Demonstrate an awareness of the impact of the media and the legal system on human error

Assessment Tasks

Name Weighting Due
Tutorial Attendance 10% Every workshop
Short written assessment 10% 25/08/2017
Presentation 25% 03/11/2017
QI Project 25% 03/11/2017
Workshop Participation 10% Throughout Semester
Weekly Quizzes 20% Before each workshop

Tutorial Attendance

Due: Every workshop
Weighting: 10%

Attending tutorials is compulsory and will make up 10% of your overall mark. 


This Assessment Task relates to the following Learning Outcomes:
  • Understand the scope, nature and causes of the most common safety problems
  • Understand human factors in theory and practice
  • Demonstrate an awareness of the impact of the media and the legal system on human error

Short written assessment

Due: 25/08/2017
Weighting: 10%

This is to be a short (200 words) description of a personal experience of a work-based error (de-identified) or other safety and quality activity (such as root cause analysis or open disclosure). Feel free to report the facts (de identified), ensure you include your thoughts and feelings on the event as well as its repercussions.  The intention is to cement your commitment to the course. 

This could form the basis of your end of term presentation or Quality Improvement Project - but doesn't have to.

 


This Assessment Task relates to the following Learning Outcomes:
  • Understand the scope, nature and causes of the most common safety problems
  • Understand human factors in theory and practice
  • Understand the nature and elements of well functioning teams in patient care and demonstrate techniques to make a team work
  • Understand what constitutes a safety culture and how to foster change
  • Demonstrate capacity to lead, coordinate and participate in quality improvement initiatives
  • Demonstrate capacity to learn from error, including the RCA Process
  • Demonstrate an understanding of personal ergonomics and determinants of human performance
  • Demonstrate an awareness of the impact of the media and the legal system on human error

Presentation

Due: 03/11/2017
Weighting: 25%

For this assessment, you are to choose (and check with John Cartmill) a safety and quality topic and prepare a 10 minute education session (inclusive of five minutes of questions/discussion). You should prepare a PowerPoint presentation with a maximum of four slides. This presentation is to form the basis of a talk that could be given as a “Grand Rounds” presentation and is limited to five minutes here only because you will be speaking to an already well informed group.

 

You should choose a topic that fascinates you, but you are required to include research in your presentation as well. These topics can be discussed at the first tutorial.


This Assessment Task relates to the following Learning Outcomes:
  • Understand the scope, nature and causes of the most common safety problems
  • Understand human factors in theory and practice
  • Understand the nature and elements of well functioning teams in patient care and demonstrate techniques to make a team work
  • Understand what constitutes a safety culture and how to foster change
  • Demonstrate capacity to lead, coordinate and participate in quality improvement initiatives
  • Understand the purpose and importance of and demonstrate competence in talking about error with clinicians, managers, patients and families, including open disclosure
  • Demonstrate an understanding of personal ergonomics and determinants of human performance
  • Demonstrate an awareness of the impact of the media and the legal system on human error

QI Project

Due: 03/11/2017
Weighting: 25%

For this assessment, you are to design a proposal for a quality improvement project for a potential or actual system-based error that you have noticed in your workplace (former or current) or even in your home. This error can be "trivial" (for example, patients' dentures that continuously go missing). You will then write a report regarding the proposal. This 800 word report should include:

  • a description of the error and how it was identified
  • a description of the investigation into the cause of the error (mini Root Cause Analysis), with reference to relevant literature
  • a description of the possible solutions to prevent further error, and
  • a quality improvement plan (relating to the chosen solution) detailing what changes were made and how and also how these changes might be evaluated and maintained.

 

The report should also demonstrate an understanding of the concepts that you have been developing though the course.


This Assessment Task relates to the following Learning Outcomes:
  • Understand the scope, nature and causes of the most common safety problems
  • Understand human factors in theory and practice
  • Understand the nature and elements of well functioning teams in patient care and demonstrate techniques to make a team work
  • Understand what constitutes a safety culture and how to foster change
  • Demonstrate capacity to lead, coordinate and participate in quality improvement initiatives
  • Demonstrate capacity to learn from error, including the RCA Process
  • Understand the purpose and importance of and demonstrate competence in talking about error with clinicians, managers, patients and families, including open disclosure
  • Demonstrate an understanding of personal ergonomics and determinants of human performance
  • Demonstrate an awareness of the impact of the media and the legal system on human error

Workshop Participation

Due: Throughout Semester
Weighting: 10%

This unit requires active participation within tutorials - we are interested in hearing everyone's perspectives and experiences. Just attending tutorials is not enough to receive marks for participation.


This Assessment Task relates to the following Learning Outcomes:
  • Understand the scope, nature and causes of the most common safety problems
  • Understand human factors in theory and practice
  • Understand the nature and elements of well functioning teams in patient care and demonstrate techniques to make a team work
  • Understand what constitutes a safety culture and how to foster change
  • Demonstrate capacity to lead, coordinate and participate in quality improvement initiatives
  • Demonstrate capacity to learn from error, including the RCA Process
  • Understand the purpose and importance of and demonstrate competence in talking about error with clinicians, managers, patients and families, including open disclosure
  • Demonstrate an understanding of personal ergonomics and determinants of human performance
  • Demonstrate an awareness of the impact of the media and the legal system on human error

Weekly Quizzes

Due: Before each workshop
Weighting: 20%

Each week there will be multiple choice and short answer questions available for you to answer. These must be submitted to Turnitin before the relevant workshop.


This Assessment Task relates to the following Learning Outcomes:
  • Understand the scope, nature and causes of the most common safety problems
  • Understand human factors in theory and practice
  • Understand what constitutes a safety culture and how to foster change
  • Demonstrate capacity to learn from error, including the RCA Process
  • Demonstrate an understanding of personal ergonomics and determinants of human performance
  • Demonstrate an awareness of the impact of the media and the legal system on human error

Delivery and Resources

This Unit has an online presence in iLearn. You will need access to the internet and a computer, as well as the ability to participate in online forums and communicate by email. 

A list of required and recommended readings is available in iLearn. You can find these through the library website.

Attendance at workshops is essential.

Policies and Procedures

Macquarie University policies and procedures are accessible from Policy Central. Students should be aware of the following policies in particular with regard to Learning and Teaching:

Academic Honesty Policy http://mq.edu.au/policy/docs/academic_honesty/policy.html

Assessment Policy http://mq.edu.au/policy/docs/assessment/policy_2016.html

Grade Appeal Policy http://mq.edu.au/policy/docs/gradeappeal/policy.html

Complaint Management Procedure for Students and Members of the Public http://www.mq.edu.au/policy/docs/complaint_management/procedure.html​

Disruption to Studies Policy http://www.mq.edu.au/policy/docs/disruption_studies/policy.html The Disruption to Studies Policy is effective from March 3 2014 and replaces the Special Consideration Policy.

In addition, a number of other policies can be found in the Learning and Teaching Category of Policy Central.

Student Code of Conduct

Macquarie University students have a responsibility to be familiar with the Student Code of Conduct: https://students.mq.edu.au/support/student_conduct/

Results

Results shown in iLearn, or released directly by your Unit Convenor, are not confirmed as they are subject to final approval by the University. Once approved, final results will be sent to your student email address and will be made available in eStudent. For more information visit ask.mq.edu.au.

Student Support

Macquarie University provides a range of support services for students. For details, visit http://students.mq.edu.au/support/

Learning Skills

Learning Skills (mq.edu.au/learningskills) provides academic writing resources and study strategies to improve your marks and take control of your study.

Student Enquiry Service

For all student enquiries, visit Student Connect at ask.mq.edu.au

Equity Support

Students with a disability are encouraged to contact the Disability Service who can provide appropriate help with any issues that arise during their studies.

IT Help

For help with University computer systems and technology, visit http://www.mq.edu.au/about_us/offices_and_units/information_technology/help/

When using the University's IT, you must adhere to the Acceptable Use of IT Resources Policy. The policy applies to all who connect to the MQ network including students.

Graduate Capabilities

PG - Discipline Knowledge and Skills

Our postgraduates will be able to demonstrate a significantly enhanced depth and breadth of knowledge, scholarly understanding, and specific subject content knowledge in their chosen fields.

This graduate capability is supported by:

Learning outcomes

  • Understand the scope, nature and causes of the most common safety problems
  • Understand human factors in theory and practice
  • Understand the nature and elements of well functioning teams in patient care and demonstrate techniques to make a team work
  • Understand what constitutes a safety culture and how to foster change
  • Demonstrate capacity to lead, coordinate and participate in quality improvement initiatives
  • Demonstrate an understanding of personal ergonomics and determinants of human performance
  • Demonstrate an awareness of the impact of the media and the legal system on human error

Assessment tasks

  • Tutorial Attendance
  • Short written assessment
  • Presentation
  • QI Project
  • Workshop Participation
  • Weekly Quizzes

PG - Critical, Analytical and Integrative Thinking

Our postgraduates will be capable of utilising and reflecting on prior knowledge and experience, of applying higher level critical thinking skills, and of integrating and synthesising learning and knowledge from a range of sources and environments. A characteristic of this form of thinking is the generation of new, professionally oriented knowledge through personal or group-based critique of practice and theory.

This graduate capability is supported by:

Learning outcomes

  • Understand the scope, nature and causes of the most common safety problems
  • Understand human factors in theory and practice
  • Understand the nature and elements of well functioning teams in patient care and demonstrate techniques to make a team work
  • Demonstrate capacity to lead, coordinate and participate in quality improvement initiatives
  • Demonstrate capacity to learn from error, including the RCA Process

Assessment tasks

  • Tutorial Attendance
  • Short written assessment
  • Presentation
  • QI Project
  • Workshop Participation
  • Weekly Quizzes

PG - Research and Problem Solving Capability

Our postgraduates will be capable of systematic enquiry; able to use research skills to create new knowledge that can be applied to real world issues, or contribute to a field of study or practice to enhance society. They will be capable of creative questioning, problem finding and problem solving.

This graduate capability is supported by:

Learning outcomes

  • Understand the scope, nature and causes of the most common safety problems
  • Understand human factors in theory and practice
  • Understand the nature and elements of well functioning teams in patient care and demonstrate techniques to make a team work
  • Demonstrate capacity to lead, coordinate and participate in quality improvement initiatives
  • Demonstrate capacity to learn from error, including the RCA Process

Assessment tasks

  • Tutorial Attendance
  • Short written assessment
  • Presentation
  • QI Project
  • Workshop Participation
  • Weekly Quizzes

PG - Effective Communication

Our postgraduates will be able to communicate effectively and convey their views to different social, cultural, and professional audiences. They will be able to use a variety of technologically supported media to communicate with empathy using a range of written, spoken or visual formats.

This graduate capability is supported by:

Learning outcomes

  • Understand the scope, nature and causes of the most common safety problems
  • Understand human factors in theory and practice
  • Understand the nature and elements of well functioning teams in patient care and demonstrate techniques to make a team work
  • Understand what constitutes a safety culture and how to foster change
  • Demonstrate capacity to lead, coordinate and participate in quality improvement initiatives
  • Demonstrate capacity to learn from error, including the RCA Process
  • Understand the purpose and importance of and demonstrate competence in talking about error with clinicians, managers, patients and families, including open disclosure
  • Demonstrate an understanding of personal ergonomics and determinants of human performance
  • Demonstrate an awareness of the impact of the media and the legal system on human error

Assessment tasks

  • Tutorial Attendance
  • Short written assessment
  • Presentation
  • QI Project
  • Workshop Participation
  • Weekly Quizzes

PG - Engaged and Responsible, Active and Ethical Citizens

Our postgraduates will be ethically aware and capable of confident transformative action in relation to their professional responsibilities and the wider community. They will have a sense of connectedness with others and country and have a sense of mutual obligation. They will be able to appreciate the impact of their professional roles for social justice and inclusion related to national and global issues

This graduate capability is supported by:

Learning outcomes

  • Understand the scope, nature and causes of the most common safety problems
  • Understand human factors in theory and practice
  • Understand the nature and elements of well functioning teams in patient care and demonstrate techniques to make a team work
  • Demonstrate capacity to lead, coordinate and participate in quality improvement initiatives
  • Demonstrate capacity to learn from error, including the RCA Process
  • Understand the purpose and importance of and demonstrate competence in talking about error with clinicians, managers, patients and families, including open disclosure

Assessment tasks

  • Tutorial Attendance
  • Short written assessment
  • Presentation
  • QI Project
  • Workshop Participation
  • Weekly Quizzes

PG - Capable of Professional and Personal Judgment and Initiative

Our postgraduates will demonstrate a high standard of discernment and common sense in their professional and personal judgment. They will have the ability to make informed choices and decisions that reflect both the nature of their professional work and their personal perspectives.

This graduate capability is supported by:

Learning outcomes

  • Understand the scope, nature and causes of the most common safety problems
  • Understand human factors in theory and practice
  • Understand the nature and elements of well functioning teams in patient care and demonstrate techniques to make a team work
  • Understand what constitutes a safety culture and how to foster change
  • Demonstrate capacity to lead, coordinate and participate in quality improvement initiatives
  • Understand the purpose and importance of and demonstrate competence in talking about error with clinicians, managers, patients and families, including open disclosure
  • Demonstrate an understanding of personal ergonomics and determinants of human performance

Assessment tasks

  • Tutorial Attendance
  • Short written assessment
  • Presentation
  • QI Project
  • Workshop Participation
  • Weekly Quizzes

Changes from Previous Offering

This unit is now being run in five 3-hour workshops, however, all the content and most of the assessments will remain the same as 2016.

This unit is now run in semester 2, rather than SM 9, and is graded instead of being pass fail.

Learning and Teaching Strategy

This unit employs a blended approach to learning with group discussions, readings with quiz questions, and written assessment tasks. Students are expected to actively participate in group discussion by preparing with the appropriate readings and quizzes. There are three broad themes in this unit of study.

 

To Err is Human

This module will cover a number of topics concerning human error and safety: how errors occur, human factors, and ways of avoiding or managing error. Broader perspectives of system error and error theory will be introduced, including:

·         How we learn

·         How we decide

·         How we act, react, and interact (work together)

·         Understanding error

o   How individuals err

o   How teams err

o   How systems err

 

To Repent is Divine

·         Responding to error

This module addresses responses to error. Protective mechanisms such as denial and projection are acknowledged and developed into an approach for learning from error (incident reporting and root cause analysis).

·         Talking about error

In this module, we will focus on how we explain and talk about error. This includes the concepts of debriefing, “difficult conversations” with colleagues, open disclosure, complaints processes, and speaking up about error. We will also discuss how best to provide leadership and support after a serious error.

 

To Persevere is Diabolical

·         Preventing error

This module covers the role of audit and quality improvement leadership, teamwork and culture as well as an overview of several error prevention systems.

·         Media, politics and the law

In this module, we will investigate the relationships between medical error, media, politics and the law. This includes consideration of high profile cases both nationally and internationally as well as how these are reported in the media and how they are fed into legislative change.

Changes since First Published

Date Description
02/08/2017 Unit schedule deleted.