Learning听
Learning practices that reinforce safe behaviors听
The Patient Safety Culture 鈥淏undle鈥� is arranged in three main parts with subsections under each; as with other safety bundles, all components (vs. a piecemeal approach) are required to improve patient safety culture. Improving patient safety culture requires sequential, iterative and simultaneous interventions that ENABLE, ENACT and LEARN.听
This section specifically examines the LEARNING components of the Bundle.听
The table below addresses learning practices that reinforce safe behaviours. The LEARNING section provides tools and resources to help leadership ensure that there are systems in place to support education and capability building, incident reporting/management/analysis, safety/quality measurement/reporting and operational improvements.听听
Click the hyperlinked text within the categories to access freely available tools and resources to support your work within this leadership area.听
Education/capability building
| Component | Resource Author | Resource Type | Resource Title |
| Leaders/staff/physicians trained in safety and improvement science, teamwork, communication | CPSI | Education Program | |
| Leaders/staff/physicians trained in safety and improvement science, teamwork, communication | CPSI | Education Program | TeamSTEPPS Canada鈩� |
| Team-based training, drills | BMJ Quality and Safety | Article | |
| Team-based training, drills | World Health Organization (2018) | Resource | |
| Team-based training, drills | Midwives magazine (May 2007) | Article | |
| Team-based training, drills | Official Journal of the Society for Academic Emergency Medicine (2008) | Article | |
| Team-based training, drills | The Australian Journal of Nursing Practice, Scholarship & Research (2015) | Article |
Incident reporting/management/analysis
| Component | Resource Author | Resource Type | Resource Title |
| Effective risk/incident reporting system for events related to patients/families and staff/physicians | CPSI | Tools & Resources | Incident Analysis |
| Structured processes for responding to and learning from safety events/critical incidents | CPSI | Tools & Resources | |
| Structured processes for responding to and learning from safety events/critical incidents | IHI (2011) | Article | |
| Structured processes for responding to and learning from safety events/critical incidents | NHS | Tools & Resources | |
| Structured processes for responding to and learning from safety events/critical incidents | HIROC | Tools & Resources | |
| Structured processes for responding to and learning from safety events/critical incidents | CPSI | Tools & Resources | Canadian Disclosure Guidelines: Being open with patients and families |
Safety/quality measurement/reporting
| Component | Resource Author | Resource Type | Resource Title |
| Regular measurement of safety culture; patient/family complaints; and staff/physician engagement | Qual Saf Health Care (2003) | Article | |
| Regular measurement of safety culture; patient/family complaints; and staff/physician engagement | University of Adelaide (2007) | Article | |
| Regular measurement of safety culture; patient/family complaints; and staff/physician engagement | Patient Experience Journal (2014) | Article | |
| Regular measurement of safety culture; patient/family complaints; and staff/physician engagement | OECD (2018) | Report | |
| Retrospective/prospective safety and quality process and outcome measures | AHRQ (2019) | Article | |
| Retrospective/prospective safety and quality process and outcome measures | Journal of Biomedical Informatics (2003) | Article | |
| Retrospective/prospective safety and quality process and outcome measures | Boston University School of Public Health | Webpage | |
| Regular, transparent reporting of safety/quality plan results | National Academy of Medicine (2016) | Article | |
| Regular, transparent reporting of safety/quality plan results | Health Informational (2011) | Report |
Operational improvements
| Component | Link | Resource Author | Resource Type | Resource Title |
| Structured methods, infrastructure to improve reliability, streamline operations | BMC Health Serv Res (2010) | Article | Does the process map influence the outcome of quality improvement work? A comparison of a sequential flow diagram and a hierarchical task analysis diagram | |
| Structured methods, infrastructure to improve reliability, streamline operations | Clinical Human Factors Group (2013) | Guide | Human Factors in Healthcare 'Taking Further Steps'. Case-studies-and-implementation-tips. | |
| Structured methods, infrastructure to improve reliability, streamline operations | Agency for Healthcare Research and Quality (2014) | Report | Improving Care Delivery Through Lean:Implementation Case Studies | |
| Structured methods, infrastructure to improve reliability, streamline operations | The Academy of Medical Sciences (2017) | Report | Engineering better care a systems approach to health and care design and continuous improvement | |
| Structured methods, infrastructure to improve reliability, streamline operations | AHRQ | Webpage | Plan-Do-Study-Act (PDSA) Cycle | |
| Structured methods, infrastructure to improve reliability, streamline operations | MedStar Health National Centre for Human Factors in Healthcare | Video | What is Human Factors in Healthcare? | |
| Structured methods, infrastructure to improve reliability, streamline operations | CMPA | Education Program | Human factors influences on performance. |
