IHI Open School Patient Safety Courses

Overview

No one embarks on a health care career intending to harm patients. But much too often, patients die or suffer injuries because of their experiences within the health care system. In this course, you’ll learn why becoming a student of patient safety is critical for everyone involved in health care today, and you will learn a framework for building safer, more reliable systems of care.

In Lesson 1, you’ll go beyond the numbers to hear from people who have experienced harm from the health care system and learn how it has changed their lives. You’ll explore the reasons that providing safe care isn’t always easy in an environment where powerful drugs, quick decisions, and persistent distractions are the norm.

Lesson 2 discusses the component parts of a culture of safety, including psychological safety, accountability, and teamwork and communication. Through different scenarios, you’ll learn about the structures and behaviors that contribute to a culture of safety and see these elements at work.

Finally, in Lesson 3, you’ll learn that organizations that successfully manage complexity have a deliberate approach to escalating the small concerns and suggestions of employees. Staff members know how to recognize problems, whom to contact, and how to get that person’s attention immediately. The leaders, in turn, avoid blame and provide the resources necessary to solve problems.

Estimated Time of Completion: 1 hour 15 minutes 

Lessons

• Lesson 1: Understanding Adverse Events and Patient Safety
• Lesson 2: Your Role in a Culture of Safety
• Lesson 3: Your Role in Building Safer, More Reliable Systems 

Course Objectives 

After completing this course, you will be able to:

1. Summarize why it is essential to improve patient safety.
2. Describe a framework for improving the safety of health care systems.
3. Identify four key elements of a culture of safety.
4. Explain why systematic learning from error and unintended events is the best response to ensuring patient safety.

Continuing Education Credits

The Institute for Healthcare Improvement designates this internet enduring activity for a maximum of 1.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This activity is approved to award 1.25 credit(s) toward Certified Professional in Patient Safety (CPPS) recertification.

This program has been approved by the National Association for Healthcare Quality for a maximum of 1.25 CPHQ continuing education credits for this event.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

• 1.25 Medical Knowledge MOC point(s) in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program
• 1.25 MOC point(s) in the American Board of Pediatrics' (ABP) Maintenance of Certification (MOC) program
• 1.25 point(s) in the CME component of the American Board of Anesthesiology's redesigned Maintenance of Certification in AnesthesiologyTM (MOCA®) program, known as MOCA 2.0®. (Please consult the ABA website, www.theABA.org, for a list of all MOCA 2.0 requirements.)
• 1.25 point(s) in the American Board of Ophthalmology's Maintenance of Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting MOC credit.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to satisfy the Lifelong Learning requirements for the American Board of Ophthalmology's Maintenance of Certification program.

Successful completion of this activity, which includes participation in the evaluation component, offers Lifelong Learning (MOC Part 2 CME) point(s) for the following boards:

• American Board of Anesthesiology (ABA)*
• American Board of Allergy & Immunology (ABAI)
• American Board of Colon & Rectal Surgery (ABCRS)
• American Board of Pathology (ABPath)
• American Board of Psychiatry & Neurology (ABPN)*
• American Board of Plastic Surgery (ABPS)*
• American Board of Nuclear Medicine (ABNM)
• American Board of Thoracic Surgery (ABTS)
• American Board of Urology (ABU)

*Approved as a Foundational Patient Safety Activity for ABA, ABPN, and ABPS

Successful completion of this activity, which includes participation in the evaluation component, offers Self-Assessment (MOC Part 2 SA) point(s) for the following boards:

• American Board of Family Medicine (ABFM) (15pts)**
• American Board of Pediatrics (ABPed) (20pts)**
• American Board of Ophthalmology (ABOP)
• American Board of Orthopedic Surgery (ABOS)
• American Board of Radiology (ABR)
• American Board of Physical Medicine and Rehabilitation (ABPMR)

**ABPed and ABFM diplomates are required to complete all the selected courses within an activity to collect MOC activity points.

It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting MOC credit.

As a Jointly Accredited Organization, the Institute for Healthcare Improvement is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. Social workers completing this course receive 1.25 general continuing education credits. 

Overview

This course provides an overview of the key concepts in the field of patient safety. You’ll learn the relationship between error and harm, and how unsafe conditions and human error lead to harm — through something called the Swiss cheese model. You’ll learn how to classify different types of unsafe acts that humans commit, including error, and how the types of unsafe acts relate to harm. Finally, you’ll learn about how the field of patient safety has expanded its focus from reducing error alone to encompassing efforts to reduce harm as well.

Lesson 1 will describe the Swiss cheese model of accident causation, which represents the ways that serious adverse events are almost always the result of multiple failed opportunities to stop a hazard from causing harm. We’ll explore how this model informs thinking about error and harm in health care.

In Lesson 2, you’ll learn how the human brain is wired to make certain kinds of mistakes. You’ll also learn to identify four kinds of unsafe acts, as defined by psychologist James Reason: slips, lapses, mistakes, and violations. Lesson 3 looks at how our understanding of harm in the health care system has changed and expanded over time.

Estimated Time of Completion: 1 hour 15 minutes 

Lessons

• Lesson 1: The Swiss Cheese Model
• Lesson 2: Understanding Unsafe Acts
• Lesson 3: A Closer Look at Harm 

Course Objectives 

Overview

This course is an introduction to the field of human factors: how to incorporate knowledge of human behavior in the design of safe systems. You’ll explore case studies to analyze the human factors issues involved in health care situations. And you’ll learn how to use human factors principles to design safer systems of care and implement effective strategies to prevent errors and mitigate their effects. Finally, you’ll learn how technology can reduce errors — even as, in some cases, it can introduce new opportunities for errors.

The purpose of Lesson 1 is to build awareness of the ways in which multiple factors in the workplace, involving both people and their surroundings, can contribute to error.

Lesson 2 introduces several ways to prevent or mitigate the effects of factors that contribute to error, and provides examples of each.

Lesson 3 discusses the advantages and disadvantages of technology and offers some suggestions on how people can design technology to mitigate the impact of factors that contribute to errors.

Estimated Time of Completion: 1 hour 15 minutes 

Lessons

• Lesson 1: Understanding the Science of Human Factors
• Lesson 2: Design Principles to Reduce Human Error
• Lesson 3: The Risks and Rewards of Technology 

Course Objectives 

After completing this course, you will be able to:

1. Explain how human factors principles apply to health care.
2. Describe how changes to processes can mitigate the effects of factors that contribute to error.
3. Define simplification, standardization, constraints, forcing functions, and redundancies.
4. Discuss the risks and benefits of using technology to improve patient safety.  

Continuing Education

The Institute for Healthcare Improvement designates this internet enduring activity for a maximum of 1.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This activity is approved to award 1.25 credit(s) toward Certified Professional in Patient Safety (CPPS) recertification.

This program has been approved by the National Association for Healthcare Quality for a maximum of 1.25 CPHQ continuing education credits for this event.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

• 1.25 Medical Knowledge MOC point(s) in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program
• 1.25 MOC point(s) in the American Board of Pediatrics' (ABP) Maintenance of Certification (MOC) program
• 1.25 point(s) in the CME component of the American Board of Anesthesiology's redesigned Maintenance of Certification in AnesthesiologyTM (MOCA®) program, known as MOCA 2.0®. (Please consult the ABA website, www.theABA.org, for a list of all MOCA 2.0 requirements.)
• 1.25 point(s) in the American Board of Ophthalmology's Maintenance of Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting MOC credit.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to satisfy the Lifelong Learning requirements for the American Board of Ophthalmology's Maintenance of Certification program.

Successful completion of this activity, which includes participation in the evaluation component, offers Lifelong Learning (MOC Part 2 CME) point(s) for the following boards:

• American Board of Anesthesiology (ABA)*
• American Board of Allergy & Immunology (ABAI)
• American Board of Colon & Rectal Surgery (ABCRS)
• American Board of Pathology (ABPath)
• American Board of Psychiatry & Neurology (ABPN)*
• American Board of Plastic Surgery (ABPS)*
• American Board of Nuclear Medicine (ABNM)
• American Board of Thoracic Surgery (ABTS)
• American Board of Urology (ABU)

*Approved as a Foundational Patient Safety Activity for ABA, ABPN, and ABPS

Successful completion of this activity, which includes participation in the evaluation component, offers Self-Assessment (MOC Part 2 SA) point(s) for the following boards:

• American Board of Family Medicine (ABFM) (15pts)**
• American Board of Pediatrics (ABPed) (20pts)**
• American Board of Ophthalmology (ABOP)
• American Board of Orthopedic Surgery (ABOS)
• American Board of Radiology (ABR)
• American Board of Physical Medicine and Rehabilitation (ABPMR)

**ABPed and ABFM diplomates are required to complete all the selected courses within an activity to collect MOC activity points.

It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting MOC credit.

As a Jointly Accredited Organization, the Institute for Healthcare Improvement is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. Social workers completing this course receive 1.25 general continuing education credits. 

Overview

Effective teamwork and communication are critical parts of the design of safe systems. In this course, you’ll learn what makes an effective team through case studies from health care and elsewhere. You’ll analyze the effects of individual behavior for promoting teamwork, communication, and a culture of safety. You will learn several essential communication tools, and you will learn how to prevent common problems associated with lapses in communication during inherently risky health care situations.

Lesson 1 discusses why effective team functioning is so critical to protecting patients from harm, including common types of errors associated with ineffective teamwork and communication. You’ll learn to distinguish teams that are working effectively from those that are not.

Lesson 2 provides specific techniques teams can use to improve their communication, such as SBAR (Situation-Background-Assessment-Recommendation), critical language, and briefings.

Lesson 3 reviews some of the most common problems associated with miscommunication during critical transitions in health care — when responsibility for a patient is transferred between providers and/or locations — and how to prevent them.

Estimated Time of Completion: 1 hour 15 minutes 

Lessons

• Lesson 1: Fundamentals of Teamwork and Communication
• Lesson 2: Tools and Techniques for Effective Communication
• Lesson 3: Safety During Transitions Across the Continuum of Care Course 

Course Objectives

After completing this course, you will be able to:

1. Explain how individual behavior and team dynamics in health care can make care safer or less safe.
2. Use structured communication techniques to improve communication within health care.
3. Specify possible interventions to improve patient safety and reduce risk during times of transition. 

Continuing Education

The Institute for Healthcare Improvement designates this internet enduring activity for a maximum of 1.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This activity is approved to award 1.25 credit(s) toward Certified Professional in Patient Safety (CPPS) recertification.

This program has been approved by the National Association for Healthcare Quality for a maximum of 1.25 CPHQ continuing education credits for this event.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

• 1.25 Medical Knowledge MOC point(s) in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program
• 1.25 MOC point(s) in the American Board of Pediatrics' (ABP) Maintenance of Certification (MOC) program
• 1.25 point(s) in the CME component of the American Board of Anesthesiology's redesigned Maintenance of Certification in AnesthesiologyTM (MOCA®) program, known as MOCA 2.0®. (Please consult the ABA website, www.theABA.org, for a list of all MOCA 2.0 requirements.)
• 1.25 point(s) in the American Board of Ophthalmology's Maintenance of Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting MOC credit.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to satisfy the Lifelong Learning requirements for the American Board of Ophthalmology's Maintenance of Certification program.

Successful completion of this activity, which includes participation in the evaluation component, offers Lifelong Learning (MOC Part 2 CME) point(s) for the following boards:

• American Board of Anesthesiology (ABA)*
• American Board of Allergy & Immunology (ABAI)
• American Board of Colon & Rectal Surgery (ABCRS)
• American Board of Pathology (ABPath)
• American Board of Psychiatry & Neurology (ABPN)*
• American Board of Plastic Surgery (ABPS)*
• American Board of Nuclear Medicine (ABNM)
• American Board of Thoracic Surgery (ABTS)
• American Board of Urology (ABU)

*Approved as a Foundational Patient Safety Activity for ABA, ABPN, and ABPS

Successful completion of this activity, which includes participation in the evaluation component, offers Self-Assessment (MOC Part 2 SA) point(s) for the following boards:

• American Board of Family Medicine (ABFM) (15pts)**
• American Board of Pediatrics (ABPed) (20pts)**
• American Board of Ophthalmology (ABOP)
• American Board of Orthopedic Surgery (ABOS)
• American Board of Radiology (ABR)
• American Board of Physical Medicine and Rehabilitation (ABPMR)

**ABPed and ABFM diplomates are required to complete all the selected courses within an activity to collect MOC activity points.

It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting MOC credit.

As a Jointly Accredited Organization, the Institute for Healthcare Improvement is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. Social workers completing this course receive 1.25 general continuing education credits. 

Overview

In this course, we’re going to describe and advocate a patient-centered approach to use when things go wrong. This approach to adverse events and medical error centers on the needs of the patient, but it is also the best way to address the needs of a caregiver in the wake of an adverse event.

In Lesson 1, we’ll discuss what caregivers should say — and how to say it — immediately after such an event occurs. Because, as you’ll see through several examples, communication is important. You’ll also learn who should handle this initial communication and who else may need to be notified about the event.

Lesson 2 offers suggestions for when and how to communicate with a patient after an adverse event, including recommendations for crafting an effective, sincere apology when it is warranted.

In Lesson 3, you’ll hear some caregivers describe how terrible they felt after an adverse event occurred in a patient’s care. You’ll learn what kind of support caregivers may need after an adverse event, including counseling, time off, and involvement on improvement teams. You’ll also learn why sometimes caregivers don’t receive the necessary support after something goes wrong and how some organizations are working to improve this.

Estimated Time of Completion: 1 hour 15 minutes

Lessons

• Lesson 1: Responding to an Adverse Event: A Step-by-Step Approach
• Lesson 2: Communication, Apology, and Resolution
• Lesson 3: The Impact of Adverse Events on Caregivers: The Second Victim Course 

Course Objectives

After completing this course, you will be able to:

1. Describe four steps to take following an adverse event.
2. Explain how to communicate effectively about bad news and when you should apologize.
3. Discuss the impact of adverse events on providers. 

Continuing Education

In support of improving patient care, the Institute for Healthcare Improvement is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the health care team.

The Institute for Healthcare Improvement designates this internet enduring activity for a maximum of 1.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This activity is approved to award 1.25 credit(s) toward Certified Professional in Patient Safety (CPPS) recertification.

This program has been approved by the National Association for Healthcare Quality for a maximum of 1.25 CPHQ continuing education credits for this event.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

• 1.25 Medical Knowledge MOC point(s) in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program
• 1.25 MOC point(s) in the American Board of Pediatrics' (ABP) Maintenance of Certification (MOC) program
• 1.25 point(s) in the CME component of the American Board of Anesthesiology's redesigned Maintenance of Certification in AnesthesiologyTM (MOCA®) program, known as MOCA 2.0®. (Please consult the ABA website, www.theABA.org, for a list of all MOCA 2.0 requirements.)
• 1.25 point(s) in the American Board of Ophthalmology's Maintenance of Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting MOC credit.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to satisfy the Lifelong Learning requirements for the American Board of Ophthalmology's Maintenance of Certification program.

Successful completion of this activity, which includes participation in the evaluation component, offers Lifelong Learning (MOC Part 2 CME) point(s) for the following boards:

• American Board of Anesthesiology (ABA)*
• American Board of Allergy & Immunology (ABAI)
• American Board of Colon & Rectal Surgery (ABCRS)
• American Board of Pathology (ABPath)
• American Board of Psychiatry & Neurology (ABPN)*
• American Board of Plastic Surgery (ABPS)*
• American Board of Nuclear Medicine (ABNM)
• American Board of Thoracic Surgery (ABTS)
• American Board of Urology (ABU)

*Approved as a Foundational Patient Safety Activity for ABA, ABPN, and ABPS

Successful completion of this activity, which includes participation in the evaluation component, offers Self-Assessment (MOC Part 2 SA) point(s) for the following boards:

• American Board of Family Medicine (ABFM) (15pts)**
• American Board of Pediatrics (ABPed) (20pts)**
• American Board of Ophthalmology (ABOP)
• American Board of Orthopedic Surgery (ABOS)
• American Board of Radiology (ABR)
• American Board of Physical Medicine and Rehabilitation (ABPMR)

**ABPed and ABFM diplomates are required to complete all the selected courses within an activity to collect MOC activity points.

It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting MOC credit.

As a Jointly Accredited Organization, the Institute for Healthcare Improvement is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. Social workers completing this course receive 1.25 general continuing education credits. 

Overview

This course introduces learners to a systematic response to error called Root Cause Analyses and Actions (RCA2). The goal of RCA2 is to learn from adverse events and near misses, and to take action to prevent them from happening in the future. By the end of this course, you’ll have a step-by-step approach for investigating an event and improving after something goes wrong.

Lesson 1 introduces RCA2 and describes the key elements of the process, including the concept of risk-based prioritization.

Lesson 2 describes how to conduct RCA2, focusing on actions that should occur within 45 days of an adverse event or near-miss incident. You’ll learn whom to include on an RCA2 team, how to conduct interviews and draw a high-level flowchart to understand what happened, and how to use what you learn to develop causal statements.

Lesson 3 takes a close look at the true purpose of RCA2: action. You will learn how to compose recommended actions so that people with appropriate authority in the system can use the findings to improve.

RCA2 is a trademark of the Institute for Healthcare Improvement. IHI does not endorse any software or training for the RCA2 process that is not directly provided by IHI. Acknowledgment: This course content is based on the report RCA2 : Improving Root Cause Analyses and Actions to Prevent Harm. IHI gratefully acknowledges the members of the expert panel who contributed to the report.

Estimated Time of Completion: 1 hour 15 minutes

Lessons

• Lesson 1: Preparing for Root Cause Analyses and Actions
• Lesson 2: Conducting Root Cause Analyses
• Lesson 3: Actions to Build Safer Systems 

Course Objectives

After completing this course, you will be able to:

1. Explain how adverse events and near misses can be used as learning opportunities.
2. Determine which events are appropriate for Root Cause Analyses and Actions (RCA Squared).
3. Describe a timeline of activities for the RCA Squared review period.
4. Describe activities that should take place during the action period of RCA Squared.

Continuing Education

The Institute for Healthcare Improvement designates this internet enduring activity for a maximum of 1.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This activity is approved to award 1.25 credit(s) toward Certified Professional in Patient Safety (CPPS) recertification.

This program has been approved by the National Association for Healthcare Quality for a maximum of 1.25 CPHQ continuing education credits for this event.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

• 1.25 Medical Knowledge MOC point(s) in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program
• 1.25 MOC point(s) in the American Board of Pediatrics' (ABP) Maintenance of Certification (MOC) program
• 1.25 point(s) in the CME component of the American Board of Anesthesiology's redesigned Maintenance of Certification in AnesthesiologyTM (MOCA®) program, known as MOCA 2.0®. (Please consult the ABA website, www.theABA.org, for a list of all MOCA 2.0 requirements.)
• 1.25 point(s) in the American Board of Ophthalmology's Maintenance of Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting MOC credit.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to satisfy the Lifelong Learning requirements for the American Board of Ophthalmology's Maintenance of Certification program.

Successful completion of this activity, which includes participation in the evaluation component, offers Lifelong Learning (MOC Part 2 CME) point(s) for the following boards:

• American Board of Anesthesiology (ABA)*
• American Board of Allergy & Immunology (ABAI)
• American Board of Colon & Rectal Surgery (ABCRS)
• American Board of Pathology (ABPath)
• American Board of Psychiatry & Neurology (ABPN)*
• American Board of Plastic Surgery (ABPS)*
• American Board of Nuclear Medicine (ABNM)
• American Board of Thoracic Surgery (ABTS)
• American Board of Urology (ABU)

*Approved as a Foundational Patient Safety Activity for ABA, ABPN, and ABP

Successful completion of this activity, which includes participation in the evaluation component, offers Self-Assessment (MOC Part 2 SA) point(s) for the following boards:

• American Board of Family Medicine (ABFM) (15pts)**
• American Board of Pediatrics (ABPed) (20pts)**
• American Board of Ophthalmology (ABOP)
• American Board of Orthopedic Surgery (ABOS)
• American Board of Radiology (ABR)
• American Board of Physical Medicine and Rehabilitation (ABPMR)

**ABPed and ABFM diplomates are required to complete all the selected courses within an activity to collect MOC activity points.

It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting MOC credit.

As a Jointly Accredited Organization, the Institute for Healthcare Improvement is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. Social workers completing this course receive 1.25 general continuing education credits. 

Overview

This course will review eight key recommendations for achieving safety on a system-wide level, as proposed by the IHI report Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human.

Lesson 1 will briefly review the complete set of recommendations, with a focus on actions for leaders of health systems.

Lesson 2 will provide a closer review of critical recommendations for supporting the health care workforce. Failure to support the health care workforce is associated with a variety of adverse consequences that ripple across the health care system, making it less safe for patients, families, and providers.

Lesson 3 focuses on how engaging patients and families as respected partners can improve the safety of care.

Acknowledgment: This course content is based on the report Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human. IHI gratefully acknowledges the members of the expert panel who contributed to the report.

Estimated Time of Completion: 1 hour 15 minutes 

Lessons

• Lesson 1: Eight Recommendations for Total Systems Safety
• Lesson 2: Supporting the Health Care Workforce
• Lesson 3: Partnering with Patients and Families 

Course Objectives

After completing this course, you will be able to:

1. List eight recommendations for leaders to accelerate patient safety and prevent harm.
2. Explain three key recommendations for promoting safety among the health care workforce.
3. Identify five strategies that empower patient and family engagement in patient safety. 

Continuing Education

In support of improving patient care, the Institute for Healthcare Improvement is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the health care team.

The Institute for Healthcare Improvement designates this internet enduring activity for a maximum of 1.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This activity is approved to award 1.25 credit(s) toward Certified Professional in Patient Safety (CPPS) recertification.

This program has been approved by the National Association for Healthcare Quality for a maximum of 1.25 CPHQ continuing education credits for this event.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

• 1.25 Medical Knowledge MOC point(s) in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program
• 1.25 MOC point(s) in the American Board of Pediatrics' (ABP) Maintenance of Certification (MOC) program
• 1.25 point(s) in the CME component of the American Board of Anesthesiology's redesigned Maintenance of Certification in AnesthesiologyTM (MOCA®) program, known as MOCA 2.0®. (Please consult the ABA website, www.theABA.org, for a list of all MOCA 2.0 requirements.)
• 1.25 point(s) in the American Board of Ophthalmology's Maintenance of Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting MOC credit.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to satisfy the Lifelong Learning requirements for the American Board of Ophthalmology's Maintenance of Certification program.

Successful completion of this activity, which includes participation in the evaluation component, offers Lifelong Learning (MOC Part 2 CME) point(s) for the following boards:

• American Board of Anesthesiology (ABA)*
• American Board of Allergy & Immunology (ABAI)
• American Board of Colon & Rectal Surgery (ABCRS)
• American Board of Pathology (ABPath)
• American Board of Psychiatry & Neurology (ABPN)*
• American Board of Plastic Surgery (ABPS)*
• American Board of Nuclear Medicine (ABNM)
• American Board of Thoracic Surgery (ABTS)
• American Board of Urology (ABU)

*Approved as a Foundational Patient Safety Activity for ABA, ABPN, and ABPS

Successful completion of this activity, which includes participation in the evaluation component, offers Self-Assessment (MOC Part 2 SA) point(s) for the following boards:

• American Board of Family Medicine (ABFM) (15pts)**
• American Board of Pediatrics (ABPed) (20pts)**
• American Board of Ophthalmology (ABOP)
• American Board of Orthopedic Surgery (ABOS)
• American Board of Radiology (ABR)
• American Board of Physical Medicine and Rehabilitation (ABPMR)

**ABPed and ABFM diplomates are required to complete all the selected courses within an activity to collect MOC activity points.

It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting MOC credit.

As a Jointly Accredited Organization, the Institute for Healthcare Improvement is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. Social workers completing this course receive 1.25 general continuing education credits. 

Overview

This course focuses on how organizations can create and foster a culture of safety. It will assist leaders in creating, shaping, and sustaining the type of culture needed to advance patient and workforce safety efforts. It is designed to inspire, motivate, and inform you as you lead your organization on its journey to zero harm.

In Lesson 1, you’ll learn how a wrong-site surgery occurred at a respected Boston hospital and how the hospital handled it immediately afterward. The lesson will also discuss a range of responses to error, including whether to disclose the mistake and whether to punish the people involved.

Lesson 2 will describe six domains of a culture of safety and provide useful tools for assessing and advancing your organization’s culture of safety.

Lesson 3 will help you determine the current state of your organization’s journey toward a culture of safety, to help set priorities and drive improvement.

Estimated Time of Completion: 1 hour 15 minutes 

Lessons

• Lesson 1: A Just Culture Case Study
• Lesson 2: Building a Culture of Safety
• Lesson 3: Understanding and Improving Organizational Culture 

Course Objectives

After completing this course, you will be able to:

1. Discuss your opinions on one hospital’s response to a serious adverse event.
2. Describe six domains of a culture of safety.
3. Explain how to use quantitative and qualitative data to assess the culture of an organization.

Continuing Education

The Institute for Healthcare Improvement designates this internet enduring activity for a maximum of 1.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This activity is approved to award 1.25 credit(s) toward Certified Professional in Patient Safety (CPPS) recertification.

This program has been approved by the National Association for Healthcare Quality for a maximum of 1.25 CPHQ continuing education credits for this event.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

• 1.25 Medical Knowledge MOC point(s) in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program
• 1.25 MOC point(s) in the American Board of Pediatrics' (ABP) Maintenance of Certification (MOC) program
• 1.25 point(s) in the CME component of the American Board of Anesthesiology's redesigned Maintenance of Certification in AnesthesiologyTM (MOCA®) program, known as MOCA 2.0®. (Please consult the ABA website, www.theABA.org, for a list of all MOCA 2.0 requirements.)
• 1.25 point(s) in the American Board of Ophthalmology's Maintenance of Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting MOC credit.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to satisfy the Lifelong Learning requirements for the American Board of Ophthalmology's Maintenance of Certification program.

Successful completion of this activity, which includes participation in the evaluation component, offers Lifelong Learning (MOC Part 2 CME) point(s) for the following boards:

• American Board of Anesthesiology (ABA)*
• American Board of Allergy & Immunology (ABAI)
• American Board of Colon & Rectal Surgery (ABCRS)
• American Board of Pathology (ABPath)
• American Board of Psychiatry & Neurology (ABPN)*
• American Board of Plastic Surgery (ABPS)*
• American Board of Nuclear Medicine (ABNM)
• American Board of Thoracic Surgery (ABTS)
• American Board of Urology (ABU)

*Approved as a Foundational Patient Safety Activity for ABA, ABPN, and ABPS

Successful completion of this activity, which includes participation in the evaluation component, offers Self-Assessment (MOC Part 2 SA) point(s) for the following boards:

• American Board of Family Medicine (ABFM) (15pts)**
• American Board of Pediatrics (ABPed) (20pts)**
• American Board of Ophthalmology (ABOP)
• American Board of Orthopedic Surgery (ABOS)
• American Board of Radiology (ABR)
• American Board of Physical Medicine and Rehabilitation (ABPMR)

**ABPed and ABFM diplomates are required to complete all the selected courses within an activity to collect MOC activity points.

It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting MOC credit.

As a Jointly Accredited Organization, the Institute for Healthcare Improvement is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. Social workers completing this course receive 1.25 general continuing education credits.