E1: Learning from error and adverse events using human factors training

Friday 29 March
13:15 – 14:30

Part A: Learning from sentinel events in healthcare; a culture shift is necessary

In the Netherlands potentially avoidable mortality did not decrease in recent years. In practice it appears that sentinel events in healthcare continue to repeat themselves. A joint approach and a learning organization/system are necessary to solve this.
The process of learning and improving can be stimulated when the sentinel events and the outcomes of the analyzes are shared with each other. A joint approach can be chosen if effective improvement recommendations are expensive or require national or even international coordination.

After this session, participants will be able to:

1. Understand how the learning cycle for sentinel events in healthcare works
2. Understand how to improve recommendations from RCA
3. Understand the basics of developing a learning organization or system

Dave Dongelmans, Intensivist, Amsterdam University Medical Centers, The Netherlands

Part B: Human Factors Issues in “Better Training, Better Births”: an evaluation study

This session will offer two elements: to provide a taster for a model of intervention in human factors training for doctors and midwives, through exposure to an experiential event; to explore the evaluation of the two-pronged programme designed to improve outcomes and mitigate against human error.
It will offer some insight into an intervention strategy and explore the extent to which it is possible to draw meaningful conclusions from short and medium term evaluations.

After this session, participants will be able to:

1. Demonstrate an understanding of some key human factors related issues, as they apply to maternity care provision
2. Recognise the challenges associated with programme evaluation and impact
3. Show awareness of the impact on practice of short term interventions

Alison Gale, Consultant Obstetrician and Gynaecologist/Director of Medical Education, Lancashire Teaching Hospitals; England.