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

• Training Hours: 1.25