1. Improve systems by identifying and critically evaluating the possible hazards and risks associated with human errors, violations and their potential underlying and systemic causes; whether this is for a new system in development, an existing system or for a planned/unplanned change
Enquiry, Analysis, Problem Solving, Application, Professional Requirement

2. Demonstrate critical awareness and the ability to critically evaluate those elements of a system that are proving successful and also those controls and barriers that have provided system resilience when called on.
Analysis and Reflection, Professional Requirement

3. Demonstrate decision making, reflection and communication skills needed for incident response and investigations under conditions of partial information and incomplete data. This will include the abilities needed to conduct successful interviews and root cause analysis
Enquiry, Analysis, Problem Solving, Professional Requirement

4. Critically reflect on lessons learnt (both positive and negative) and clearly communicate appropriate improvement actions to achieve sustainable improvement
Application, Communication, Reflection

Produce a reflexive discussion document that critically evaluates your success with either; Planning and undertaking a Human Factors risk assessment OR planning and undertaking an assessment of good practice at your workplace. This assignment must be submitted by the end of week 39.

Produce a reflexive discussion document that critically analyses an incident investigation (for a simulated event) and the appropriateness of any suggested improvement actions and communication strategy. This assignment must be submitted by the end of week 45.


Addditional Assessment Details
Summative Assessments:
1. The first reflexive discussion document will be based on a Human Factors risk study or a Human Factors study of good practice that you have undertaken. The appendix will constitute part of the summative assessment. The discussion document should reflect on your performance plus the appropriateness of the methodology and its link to risk and safety theories. This assignment must be submitted by the end of week 39.
This assessment demonstrates achievement of Learning outcomes 1,2 and 4

2. The second reflexive discussion document is highly dependent upon your incident investigation report that you will need to provide within an appendix and will form part of the assessment. This assignment must be submitted by the end of week 45.
This assessment demonstrates achievement of Learning Outcomes 3 and 4.

Formative Assessments:
During this module you will have access to multiple choice tests to check your knowledge and understanding and you will be given the opportunity to use different types of risk assessment. This links to all outcomes.

You will also be encouraged to contribute your opinions and answers to related questions posed on the discussion board which will provide an opportunity for feedback. This links to all outcomes.

You will have a final opportunity to receive feedback on your professional CIEHF competencies logbook portfolio. Learning outcomes 1-3

An understanding of the concept of risk is key to making informed decisions when assessing the cost-benefit of improving a system. This module will introduce you to the concept of risk and risk assessment. These concepts will then be linked to Human Factors within social systems and socio-technical systems that are there to provide patient and service user care.

This module will provide you with:

1. An Introduction to risk and associated concepts such as: Human Errors and Violations, Error Causes, Underlying and Systemic causes of error, barriers, controls, control hierarchy, stop cards, hazards, risk taking, risk ranking, severity rating, quantitative and qualitative risk assessment and cost benefit analysis techniques.

2. The key error, violations and safety theories and models will be introduced and discussed, and whether there is value from learning from the past – ie do organisations have a memory and the evidence base for the use of case studies.

3. An understanding of the need to be proactive and how this may be achieved to enable you to identify and communicate potential risks and actual successes, including the success of barriers and controls.

4. A rationale for why system changes (both intended and unintended) can introduce hazards, remove barriers or reduce error tolerance and the theories associated with safety management systems.

5. Techniques that can support you when responding to an incident as it starts to occur; including undertaking a situational assessment, decision making and seeking support of those involved, including patient and family.

6. Tools and techniques for Incident investigations, data collection and root cause analysis, including when and to what extent you should investigate. This will include how and when to involve the patient/service user, their family and carers. You will consider how to produce an effective report in order to achieve learning and sustainable improvement.

We need to recognise that it is possible to learn Proactively from success and by identifying the potential for things to go wrong in the future, as well as Reactively from the past experiences of patients/service users and safety incidents.

From a Proactive Perspective: This module will explore the concepts of hazards and risk, including the link to errors and violations, and how you can assess risk in order to prioritise improvements. You will also be introduced to the theories of ‘learning from success’ and practical techniques for identifying the reasons for success so that this knowledge can be applied elsewhere.

From a Reactive Perspective: You will develop the knowledge and skills to respond to an incident as it unfolds and those needed to appropriately investigate and record a safety incident, communicate the learning opportunities, whilst supporting all those involved or affected.

This module will commence with an Introduction to Risk and its various components. You will also be provided with an overview of the module topic areas.

More generally, a new topic area will be released each week and once released these materials will remain open for you to use at any time, at your own pace. Each topic will start with an introduction and will then provide guided learning opportunities and formative feedback exercises.

This module will continue to make use of the discussion board and you will be encouraged to interact with each other and with your module lecturers.

A simulated incident will be introduced during the module and you will have the opportunity to be part of an on-line investigation team.

As well as scheduled teaching and learning activities, you will be expected to undertake both guided independent study, which includes formative assessments, and independent study to consolidate your learning.

Scheduled Teaching and Learning Activities: (15)
Video and online lectures, interactive discussion board, on campus exercises, discussions and simulations

Guided Independent Study Hours: (55)
Online materials, tasks and links

Independent Study Hours: (130)
Assignment writing, making entries to your logbook portfolio, additional reading and researching

HSE (1999) HSG48, Reducing Error and Influencing Behaviour, second edit. London: HMSO

Hollnagel, E., Wears, R.I. and Braithwaite, J. (2015) From Safety I to Safety II: A White Paper. The Resilient Health Care Net: published simultaneously by the University of Southern Denmark, University of Florida, USA and Macquarie University, Australia. Also available electronically at https://www.england.nhs.uk

Hollnagel, E. (2017) Safety II in practice. Routledge

Hollnagel, E., Braithwaite,J. and Wears, R.I. Eds. (2018) Delivering Resilient Health Care. Routledge

Rausand, M. and Haugen, S. (2020) Risk Assessment: Theory, methods and applications, second edit. Wiley Blackwell

Reason, J.T. (2017) A Life in Error: from little slips to big disasters. Boca Raton Florida USA: CRC Press

Successful completion of this module will require you to have access to a Computer and good internet access

Pre-requisites Must have studied Module 1 Introducing Human Factors and Module 2 The Systems Approach