All learning outcomes for this module are listed below.  Assessment Criteria and guidance follows the learning outcome which gives an indication as to how each outcome can be achieved.

·         Develop knowledge and understanding of decision making, judgements, reasoning skills and problem solving methodologies within health and social care settings.

·         Analyse the comparative theories within the reasoning domain.

·         Analyse the impact of patient safety policy.

·         Utilise a problem solving approach to decision making, risk assessment and hazard avoidance.

·         Take responsibility for and effectively communicate decisions and judgements made in the practice setting.

·         Develop the ability to critically evaluate evidence supporting professional practice and making informed decisions.

·          a critical evaluation of evidence supporting professional practice and making informed decisions.

Identify either a near-miss or an incident (not an identifiable serious event)

Consider:

ž  Process of clinical decision making

ž  Professional judgement

ž  Error in decision making

ž  Clinical reasoning and expertise – Novice to Expert

ž  Contributory factors involved in the situation

ž  Decision making theories to explain actions

ž  Explore the reasons and use theoretical perspectives to explain and analyse the factors involved

ž  What went wrong and why did it go wrong

ž  Identify risk management tools to help you ‘pull apart’ the case to make sense of what went wrong

Introduction – 250 words

Setting the scene re-patient safety. The need for improving safety and understanding error.

Refer to current policy documents from the DH. The impact of error in healthcare

Identify key themes, risk management tools and the specific decision making theories you will apply.

Main Body  –   Approx  2000 words

Event

Introduce your near-miss or incident with a detailed appendix if needed.

Explain the overall situation using risk management theory and cause and effect.

You select whichever risk management tool you want to use to help analyse the case. Apply risk theory. Identify both human and system factors involved and critically analyse to demonstrate your understanding.

For example:

The Swiss Cheese model may help you to explain the bigger perspective and how/why things went wrong in your event. Was there a lack of safety-netting, checking mechanisms in the system?  Consider where there were holes in the system which lead to the error.

If you select the Fishbone to analyse your event;

Explain the tool and identify the contributory factors involved in the event. If there are many contributory factors then you will need to select a few key factors to focus on, otherwise you will not have enough word count to allow you to address all the contributory factors. Make this clear in your introduction

ž  Individual factors such as lack of knowledge or experience

ž  Task factors = unavailable test results or protocols

ž  Team factors such as inadequate supervision or poor communication

ž  Work environment  =  high workload, low staffing levels, equipment problems

ž  Equipment =  failure in technology or user error

Then complete the fishbone and place it in the appendices.

Three Buckets Theory

This model may help you to analyse an individuals actions, for example a prescribing error due to a unfamiliar drug dose within a new clinical setting. Consider the task, self and context specific to the individual and the system in which they work. Analyse how and why it went wrong.

Decision Making

Explore the recognition of factors.

Individual factors such as lack of knowledge or experience; how did you recognise this; what evidence did you have; was it a known fact or assumption?

Team factors such as inadequate supervision or poor communication – how are you judging this view, based on what prior knowledge or experience? What does poor mean?

Ensure you recognise both intuitive and experiential factors and information processing

Conclusion  300 words

Draw together the importance of understanding & managing patient safety to prevent error in practice.

The relevance of the individuals ability to make knowledgeable, informed decisions to ensure accurate safe professional judgement in practice.

Appendices

ž  Case details

ž  Risk Management tool completed with relevant information/factors

ž  No policy documents

ž  Maximum of 4

Important

ž  You are not doing a formal investigation

ž  You are not expected to change practice or introduce a solution

ž  You must not conduct interviews or any formal enquiries about the situation