PS 102: From Error to Harm
PS 102: From Error to Harm
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.
Course Objectives
After completing this course, you will be able to:
- Explain the Swiss cheese model of error.
- Define active failures and latent error and discuss their roles in causing harm.
- List the main types of unsafe acts utilizing James Reason’s classification system.
- Explain why patient safety experts recommend focusing less on reducing errors and more on reducing harm.
Lessons
- Lesson 1: The Swiss Cheese Model
This lesson 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.
- Lesson 2: Understanding Unsafe Acts
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: Your Role in Building Safer, More Reliable Systems
This lesson 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
Continuing Education Credits
Course completion typically earns 1.25 Continuing Education credits. Please read the full details to ensure that this course offers your desired credit type. Learn more about Continuing Education credits
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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 activity/program is approved by NAHQ® for 1.25 CPHQ CE credits.
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.
Members of the College of Family Physicians of Canada are eligible to receive Mainpro+ Certified, Certified Assessment, or Non-Certified credits for participation in this activity due to reciprocal agreement with the American Academy of Family Physicians.
The AAFP has reviewed PS 102: From Error to Harm and deemed it acceptable for up to 1.25 Enduring Materials, Self-Study AAFP Elective credit(s). Term of Approval is from 06/20/2024 to 06/20/2025. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
For Hamad Medical Corporation Open School users, a DHP licensed practitioner can claim Category 2—Self- Directed Learning—Clinical Practice—Completing Self-Learning Modules by uploading their certificate to the CPD ePortfolio.
By attending PS 102 offered by the Institute for Healthcare Improvement participants may earn up to 1.25 ACHE Qualifying Education Hours toward initial certification or recertification of the Fellow of the American College of Healthcare Executives (FACHE) designation.
Subscriptions
This course is available in the following IHI Open School subscriptions: