Lesson 1: Introduction to Patient Safety

In this lesson, the learner will learn about the sources of errors that may compromise patient safety in the hospital, particularly in the context of emergency department as well as the impact of diagnostic errors on patient safety. The learners will also learn about the influence of the clinician’s thought processes on patient safety.

By the end of this lesson, the learners will be able to

1. Describe the WHO-International Classification for Patient Safety (WHO-ICPS) conceptual framework of patient safety and patient safety culture
2. Describe the sources of errors that can affect patient safety
3. Be aware of the tendency for blame culture when things go wrong
4. Explain the Swiss-cheese model for the manifestation of active diagnostic errors
5. Perform root cause analysis using the Ishikawa fish bone diagram and the 5 'Why's approach
6. Apply the 7 'M's, the London Protocol of system analysis of clinical incidents and the 7 groups of 'waste' ('muda') as groups of causes in the fish bone diagram