Define reliability, and describe how reliability can be measured and expressed.
Describe, using Reason’s Swiss Cheese Effect, how human error and latent system weaknesses combine to cause loss events in health care.
Describe, using Cook and Wood’s Sharp-End Model, how culture can shape behavior and prevent human error that contributes to loss events.
Provide examples for each of, the five (5) behavior-shaping factors of reliable systems: structure, protocol, culture, process, and intuitive environment.
Apply, in the context of Patient Safety Culture, the three steps to culture change.Summarize the process for selecting Patient Safety Culture behaviors for a hospital or a service line or a single unit.
Identify safety behaviors, and describe the use of each behavior, for each of the three (3) human error types in the Generic Error Modeling System (GEMS).
Examine leader behaviors, and describe the use of each behavior, for high reliability organizations.
Describe several different models for making problems visible including: incident reporting, stopping the line, visual control, and simplified data presentation. Learn how to move data closer to the source and the impact this has on the speed of correction. Understand the common patterns in building a culture which stops to fix problems.