| CODE | HSL5004 | ||||||||||||
| TITLE | Implementation of Integrated Safety Across the Levels of the Healthcare Ecosystem | ||||||||||||
| UM LEVEL | 05 - Postgraduate Modular Diploma or Degree Course | ||||||||||||
| MQF LEVEL | 7 | ||||||||||||
| ECTS CREDITS | 10 | ||||||||||||
| DEPARTMENT | Health Systems Management and Leadership | ||||||||||||
| DESCRIPTION | Adverse events may affect the personal life, family and work of healthcare professionals involved. Healthcare professionals are considered as the ‘second victim’ in the circumstance of adverse events. Adverse events also negatively impact and damage the reputation of affected health organisations – considered as third victims by undermining people’s trust in these institutions and in the delivery of healthcare. There is increasing literature addressing the organisational impacts after adverse events as the third victim phenomenon. Preventive and supportive interventions to prevent and minimise the impact of adverse events will be considered at and across the different levels of the health system: - at the macro level (legislative, regulatory, professional associations, trade unions, occupational health and safety), - at the meso level (at the level of healthcare service providers) - at the micro level (at the level of patient care involving frontline healthcare professionals, carers and patients) This study unit is intended to give the knowledge and skill to health care professionals and managers working at the different levels of health and social care to empower them to prevent adverse events and emergencies and to be knowledgeable and skilled on how to deal with them when they happen. This study unit is also intended to give knowledge to professionals who support healthcare workers after an adverse event including Human Resources and Occupational Health and Safety Managers, Psychologists, Lawyers. This study unit is aimed to incorporate different aspects relevant to the preventing and dealing with adverse events including corrective and preventive actions, building resources and infrastructure required such as employee support programmes, psychological safety and support, occupational health and safety, legal framework, governance structures. The unit will consider all the levels of the healthcare ecosystem and the need for an integrated approach. This study unit should cover knowledge as well as emphasise the skills and behavioural aspects needed in practice. Topics to consider include the following: Skills supporting the safety culture in healthcare -communication, CANDOR -leadership -teamwork across professions and with management -interprofessional training, -speaking up about mistakes - impact of safety culture on practice, avoiding defensive practice -healthcare worker stigma, fear and shame to speak up, invincible attitude, failure culture, learning from experience -emotional impact of errors, managing emotions -caring for self, coping behaviours, -occupational disease / sensitivity to mental health issues -dealing with aggressive and abusive/disrespectful behaviours The ‘victims phenomena’ -the first, second and third victims phenomena -the victims phenomena in association / as an extension of patient safety, professional safety and organisational safety -second victims as an occupational disease -perspectives of the ‘victims’ phenomenon by different stakeholders -Eurobarometer, measurement of citizens perceptions Safety culture -patient safety culture, the patient safety experience -theoretical framework and factors constituting patient safety culture -tools for measurement and monitoring of patient safety culture and safety experience -safety culture within healthcare organisations -learning from mistakes and near misses -safety culture across the healthcare ecosystem -healthcare professional safety and psychological safety -just culture, blame free-culture, safe culture Governance across the healthcare ecosystem -adverse events reporting and learning from adverse events -factors affecting adverse events reporting -quality management, continuous improvement at the organisational level; monitoring and evaluation -the learning organisation -organisational culture, public and private organisaitons, ‘political’ impact / pressure -the impact of just culture on patient safety and safety of different stakeholders -corrective and preventive actions within healthcare organisations -licensing / accreditation of healthcare services and organisations -monitoring of health care outputs at the organisational level -monitoring and evaluation of outcomes at the national level -regulation of healthcare professionals The legal and ethical frameworks for safety within the healthcare ecosystem -ethical aspects related to stakeholder safety at the different healthcare levels -confidentiality and anonymity -mistakes, honest mistakes, intentional / unintentional mistakes, dealing with mistakes, unanticipated events -liability, tort and litigation, paying for errors -legislation on patient safety and second victims -disclosure and protection of healthcare professionals -disclosure to patients and its impact, defensive approaches -use of adverse events for legal purposes -conflicting interests of stakeholders and protection of stakeholders -anonymisation of adverse events reports -compensation systems / legislation -occupational health and safety legislation in healthcare -professional indemnity and insurance Institutional support initiatives and intervention programs -second victim support programs for healthcare workers involved in -patient safety incidents and peer support programs -employee support initiatives, employee safety programs, -burnout of healthcare professionals and sustainability of healthcare systems -creating awareness, development, resources and design, implementation, evaluation, sustainability -learning from institutional and peer support programs in other countries e.g. RISE, MISE, PSU (Germany) -role of professional associations, -role and impact of trade unions - protection of the initiative through the legal framework -learning from safety initiatives in other areas such as aviation - escalation of support systems: peer support, crisis intervention, Dealing and coping with situations of adverse events -possibility of working in simulation centres -use of case studies from practice -addressing adverse events within the hospital environment -training in a safe environment -seeking, receiving and accepting emotional support, coping strategies -giving and receiving peer support -emotional first aid training Study-Unit Aims: - To provide knowledge of the impact of adverse events on patients, healthcare workers, health provider organisations and the wider ecosystem - To provide knowledge of factors affecting the victims phenomenon including national legislation and regulation, patient safety culture, organisational culture across the healthcare ecosystem - To provide knowledge and develop skills for the development and application of different approaches to prevent and tackle adverse events at the macro, meso and micro level which support safety of the different stakeholders across the ecosystem - To nurture skill and behaviour which support the management and dealing with adverse events and enforces the adoption of a just culture across the ecosystem - To provide knowledge and develop skills to deal with legal implications related to adverse events - To provide knowledge and teach skill and behaviour for the stakeholders to act ethically Learning Outcomes: 1. Knowledge & Understanding: By the end of the study-unit the student will be able to: - implement practice which secures patient safety, - predict and identify risks and incident causes and impacts - design for emergency preparedness and corrective and preventive action - apply corrective and preventive actions to minimize the impact from adverse events - classify and explain the concepts of first, second and third victims and relationships between them - classify adverse events, mistakes and near-misses and variables / factors concerned - identify the consequences of adverse events in patients, significant others, healthcare professionals, healthcare management and organisations and teams - categorise and analyse different cultural and legal contexts and factors: safety culture, just culture, tort, litigation, approach for dealing with mistakes - roleplay, appraise and implement potential interventions to support patients and significant others, - roleplay interventions to support healthcare workers when they are impacted by adverse events, crises and burn out - appraise and critique factors that help health organisations to maintain a safety climate and avoid medical errors - demonstrate cultural differences in the interpretation of meaning of errors and how to deal with them in different countries and inter-profesionallly - apply the correct attitude and behaviour when dealing with all stakeholders including patients and their relatives after an adverse event - appraise the relevance of the legal framework on safety and practice - practice psychological safety and demonstrate ability to seek help - implement occupational health and safety policies - describe and discuss professional insurance and indemnity, professional code of practice and code of ethics - demonstrate ability to deal with adverse events considering the perspective of the different stakeholders across the ecosystem 2. Skills: By the end of the study-unit the student will be able to: - implement practice which secures patient safety, - predict and identify risks and incident causes and impacts - design for emergency preparedness and corrective and preventive action - apply corrective and preventive actions to minimize the impact from adverse events - classify and explain the concepts of first, second and third victims and relationships between them - classify adverse events, mistakes and near-misses and variables / factors concerned - identify the consequences of adverse events in patients, significant others, healthcare professionals, healthcare management and organisations and teams - categorise and analyse different cultural and legal contexts and factors: safety culture, just culture, tort, litigation, approach for dealing with mistakes - roleplay, appraise and implement potential interventions to support patients and significant others, - roleplay interventions to support healthcare workers when they are impacted by adverse events, crises and burn out - appraise and critique factors that help health organisations to maintain a safety climate and avoid medical errors - demonstrate cultural differences in the interpretation of meaning of errors and how to deal with them in different countries and inter-profesionallly - apply the correct attitude and behaviour when dealing with all stakeholders including patients and their relatives after an adverse event - appraise the relevance of the legal framework on safety and practice - practice psychological safety and demonstrate ability to seek help - implement occupational health and safety policies - describe and discuss professional insurance and indemnity, professional code of practice and code of ethics - demonstrate ability to deal with adverse events considering the perspective of the different stakeholders across the ecosystem Main Text/s and any supplementary readings: Main Texts: - Vincent, C. (2001). Clinical Risk Management. 2nd Edition, BMJ Books, London - Vincent, C. (2010). Patient Safety. Wiley Books, London - Waterson, P. (Ed.). (2018). Patient safety culture: theory, methods and application. CRC Press - Goeschel, C. A., Wachter, R. M., & Pronovost, P. J. (2010). Responsibility for quality improvement and patient safety: hospital board and medical staff leadership challenges. Chest, 138(1), 171-178. Supplementary Readings: - Beirão, G., Patrício, L. and Fisk, R.P. (2017), "Value cocreation in service ecosystems: Investigating health care at the micro, meso, and macro levels", Journal of Service Management, Vol. 28 No. 2, pp. 227-249. https://doi.org/10.1108/JOSM-11-2015-0357 - Buttigieg, S. C., Tomaselli, G., Byers, V., Cassar, M., Tjerbo, T., & Rosano, A. (2019). Corporate social responsibility and person-centered care: a scoping review. Journal of Global Responsibility. - Caldwell, S. and Mays, N., 2012, Studying policy implementation using a macro, meso and micro frame analysis: the case of the Collaboration for Leadership in Applied Health Research & Care (CLAHRC) programme nationally and in North West London, Health Research Policy and Systems, 10.32. doi: 10.1186/1478-4505-10-32 - Chandler, J.D. and Vargo, S.L. (2011) Contextualisation and value-in-context: how context frames exchange”, Marketing Theory, 11(1) 35-49. DOI: 10.1177/1470593110393713- - Clarkson, M.D., Haskell, H., Hemmelgarn, C, Skolnil, P.J. 2019 Abandon the term “second victim” British Medical Journal, 364:I1233 doi: 10.1136/bmj.I1233 COST (European Cooperation in Science and Technology) https://www.cost.eu/ [accessed 21052023] - ERNST COST Action CA 19113 (The European Researchers’ Network Working on Second Victims) https://cost-ernst.eu/ [accessed 21052023] - ERNST, The European Researchers’ Network Working on Second Victims, ERNST Training Manual. ERNST- COST Action CA19113, https://trainingmanual.cost-ernst.eu/ - Finney, R.E., Czinski S., Fjerstad, K., Arteaga, G.M,, Weaver, A.L,, Riggan, K.A,, Allysse, M.A,, Long, ME,, Torbenson V.E,, Rivera-Chiauzzi E.Y. 2021. Evaluation of a Second Victim Peer Support Program on Perceptions of Second Victim Experiences and Supportive Resources in Paediatric Clinical Specialties Using the Second Victim Experience and Support Tool (SVEST), Journal of Paediatric Nursing, 61 312-317 https:/doi.ord/10.1016/j.pedn2021.06.023 - Hughes, G., Shaw, S.E., Greenhalgh, T. 2020. Rethinking Integrated Care: A Systematic Hermeneutic Review of the Literature on Integrated Care Strategies and Concepts, The Milbank Quarterly, pp. 1-47. - Liukka, M., Steven, A., Flores Vizcaya Moreno, M., Sara-aho, A.M., Khakurel, J., Pearson, P., Turunen, H., Tella, S. (2020) Action after Adverse Events in Healthcare: An Integrative Literature Review, International Journal of Public Health, 17, 4717; doi:10.3390/ijerph17134717 - Mira, J.J. 2023 Understanding Honest Mistakes, Second Victims and Just Culture for Patient Safety, Journal of Healthcare Quality Research, 38, 359-261. https://doi.org/10.1016/j.jhqr.2023.08.001 - Mira, J.J., Lorenzo, S., Carillo, I., Ferrus, L., Perez-Perez, P., Iglesias, F., Silvestre, C., Oliviera, G., Zavala, E., Nuno-Solinis, R., Maderuelo-Fernandez, J.A., Vitaller, J., Astier, P. 2015. Interventions in health organisations to reduce the impact of adverse events in second and third victims, BMC Health Services Research, 15: 341 doi 10.1186/s12913-015-0994-x - Muethel., M., Frei, C., and Hollensbe, E. (2023) Erring Professionals as Second Victims: Grappling with Guilt and Identity in the Aftermath of Error, Academy of Management Journal, https://doi.org/10.5465/amj.2021.1132 - Rafter, N., Hickey, A., Condell, S., Conroy, R., O'Connor, P., Vaughan, D., Williams, D. (2015) Adverse events in healthcare: learning from mistakes. QJM: An International Journal of Medicine, Volume 108, Issue 4, April 2015, Pages 273–277 https://doi.org/10.1093/qjmed/hcu145 - Russ, M.J. (2017) Correlates of the third victim phenomenon, Psychiatric Quarterly, 88:917-920. Doi.10.1007/s11126-017-9511-1 - Sanchez-Garcia, A., Saurin-Moran, P.J., Carrillo, I., Tella, S., Polluste, K., Srulovici, E., Buttigieg, S.C., Mira, J.J. (2023) Patient safety topics, especially the second victim phenomenon, are neglected in undergraduate medical and nursing curricula in Europe: an online observational study. BMC Nursing 22: 283 https://doi.org/10.1186/s12912-023-01448-w - Sawatzky, R., Kwon, J.Y., Barclay, R., Chauhan, C., Frank, L., van den Hout, W.B., Nielsen, L.K., Nolte, S., Sprangers, M.A.G, the Response Shift – in Sync Working Group. 2021. Quality of Life Research, 30:3343-3357. https://doi.org/10.1007/s11136-021-02766-9. - Scott, S.D., Hirschinger, L.E., Cox, K.R., McCoig, M., Brandt, J., Hall, L.W. (2009) The natural history of recovery for the healthcare provider “second victim” after adverse patient events, Quality and Safety in Health Care, 18:325-330 doi: 10.1136/qshc.2009.032870 - Seys, D., Wu, A.W., Van Gerven, E., Vleugels, A., Euweman., M., Panella, M., Scott, S.D., Conway, J., Sermeus, W., Vanhaecht, K. (2012) Health Care Professionals as Second Victims after adverse events: A systematic review, Evaluation and the Health Professions, 36(2) 135-162 doi: 10.1177/0163278712458918 - Treiber, L.A. and Jones, J.H. (2018) After the medication error: recent nursing graduates’ reflections on adequacy of education, Journal of Nursing Education, 57(5) 275 – 280 doi:10.3928/01484834-20180420-04 - Tumelty, M.E. (2021) Exploring the emotional burdens and impact of medical negligence litigation on the plaintiff and medical practitioner: insights from Ireland. Legal Studies, 41, 633-656.doi:10.1017/lst.2021.20 - Tumelty, M.E. (2021) The Second Victim: a contested term? Journal of Patient Safety, 17 (8) doi:10.1097/PTS.0000000000000558 - Tumelty, M.E., (Criminal responsibility for medical injury: as helpful or harmful mechanism for patient safety? Medical Law International, 21(4) 289-292 doi:10.1177/09685332211064806 - Valentijn, P.P. 2017 Rainbow of Chaos: A study into the Theory and Practice of Integrated Primary Care. International Journal of Integrated Care, 16(2): 3, 1-4 http//dx.doi.org/10.5334/ijic.2465 - Vanhaecht, K., Seys, D., Schouten, L., Bruyneel, L., Coeckelberghs, E., Panella, M., Zeeman, G., (2019) Duration of second victim symptoms in the aftermath of a patient safety incident and association with the level of patient harm: a cross-sectional study in the Netherlands BMJ Open 9:e029923 doi:10.1136/bmjopen-2019-029923 - Vanhaecht, K., Seys, D., Russotto, S., Strametz, R., Mira, J., Sigurgeirsdottir, S., Wu, A.W., Polluste K., Popovici, D.G., Sfetcu, R., Kurt, S., Panella, M. (2022) An Evidence and Consensus-Based Definition of Second Victim: A strategic topic in healthcare quality, patient safety, person-centredness and human resource management, International Journal of Environmental Research and Public Health, 19(24), 16869 https://doi.org/10.3390/ijerph192416869 - Watermann, A.D., Garbutt, J., Hazel, E., Dunagan, W.C., Levinson, W., Fraser, V.J. and Gallagher, T.H. (2007) The emotional impact of medical errors on practising physicians in the United States and Canada. Joint Commission Journal on Quality and Patient Safety, 33(8), 467-476. https://doi.org/10.1016.S1553-7250(07)33050-X - Wu, A.W., (2000) Medical error: the second victim, The doctor who makes the mistake needs help too, British Medical Journal, 320, 726-727. - Wu, A.W. and McCay, L. (2012) Medical error: the second victim, British Journal of Hospital Medicine, October 2012, Vol 73, 10 C146- C148. - Zhang, X., Li, Q., Guo, Y., Lee, S.Y., (2019) From organisational support to second victim-related distress: role of patient safety culture. Journal of Nursing Management, 27: 1818-1825. doi:10.1111/jonm.1288. |
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| ADDITIONAL NOTES | Pre-requisite Qualifications: As per MSc in Patient Safety and Clinical Risk Management | ||||||||||||
| STUDY-UNIT TYPE | Indep Study, Grp Learn, Lect, Seminar & Tutorial | ||||||||||||
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The University makes every effort to ensure that the published Courses Plans, Programmes of Study and Study-Unit information are complete and up-to-date at the time of publication. The University reserves the right to make changes in case errors are detected after publication.
The availability of optional units may be subject to timetabling constraints. Units not attracting a sufficient number of registrations may be withdrawn without notice. It should be noted that all the information in the description above applies to study-units available during the academic year 2024/5. It may be subject to change in subsequent years. |
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