Learning from adverse events

At-a-glance

Delivery: Online
Provider: CIEHF
Format: Text, video and quizzes
Duration: Self paced, 30- 45 minutes
Price: Free!

About this Bitesize Learning

This module delves into how adverse events in organisations are more often caused by systemic issues than by individual faults. It examines the dynamics of how human interactions with systems can result in mistakes, emphasising that these errors frequently indicate wider systemic challenges. The module focuses on how to learn from these incidents to improve the overall system.

By the end of this module, you will be able to:

• Outline how adverse events in complex systems are often due to systemic issues rather than individual mistakes, and how breakdowns in system processes, protocols, or design contribute to these events.

• Describe the importance of the human factors perspective, recognising the positive role of people in systems and the resilience of well-designed systems to various types of failures, including human, organisational, and technical.

• Distinguish between intentional and unintentional unsafe acts, understanding the categorisation of unsafe acts into violations (intentional) and errors (unintentional), as well as their implications for system safety and reliability.

• Outline the five-stage process of investigating adverse events and the importance of a risk-based approach that avoids outcome bias and fosters a 'just culture'.

• Describe the negative impacts of a blame culture in organisations and the importance of fostering a culture of learning and continuous improvement.

  Ready to go?