Information and credits

The RCN would like to thank the management and staff at Whipps Cross Hospital who gave us access to the clinical simultation unit and feature in the patient scenarios presented in this learning resource.

Special thanks to Lynda Bonner and Dr Roopen Arya, VTE specialist clinicians at King's College Hospital for their clinical advice on the management of venous thromboembolism.

Who is this learning for?

This learning area is relevant to all registered nurses, student nurses, health care assistants (HCAs) and assistant practitioners working in any health care setting or specialism. The aim is to highlight the 'big picture' of how patient safety issues arise using two case scenarios that link to three other key sections that will support members of the nursing team to better understand the core concepts and human factors that underpin patient safety. It also provides tools and techniques that can be applied by individual nursing staff members to improve patient safety in their work setting.

Learners can work through this resource at their own pace either all at once, or by one of the “bite sized” pieces of learning whenever it is convenient for them.

Learning outcomes

After completing all the sections and activities in this resource, the learner should be able to:

Explain the key elements in the way patient safety incidents evolve.
Describe three core concepts in patient safety in terms of: Reason's 'Swiss Cheese' and 'Three Bucket' models and the 'Iceberg' model.
Explain how human factors impact on patient safety.
Describe at lease three tools or techniques individual nursing staff can use to improve patient safety in their practice.

Principles of Nursing Practice

The eight Principles of Nursing Practice can be applied to this learning resource however, the principles that feature most predominantly are:

Principle C - managing and being vigilant about risk.
Principle E - communicating effectively: assessing, recording and reporting on treatment and care, and are conscientious in reporting issues of concern.
Principle F - having up-to-date knowledge and skills.

These principles provide a useful framework for writing a reflective record of your learning. You may also think of ways you can draw on the remaining principles based on your own clinical experience and observations.

Relevant KSF dimensions

Core 2 - Personal and people development.
IK3 - Knowledge and information resources.

The development team

This resource was written by Alex Mathieson RN, BA (Hons).
The interactive elements were designed and developed by John Heseltine BA (Hons) and George Reith.

The review panel

Thanks to the following people for their review of the materials in this learning area:

Rosie Brown, Programme Manager, Online Learning, Royal College of Nursing.
Kirstine Buckley, Infection Prevention and Control Nurse, Dr Gray's Hospital, Scotland.
Sue Harkness, Health Care Assistant, St Anthony's Health Centre, Newcastle upon Tyne.
Caroline Lecko, Patient Safety Lead, National Patient Safety Agency.
Ross Scrivener, Programme Manager, Integrated Online Resources, Royal College of Nursing.
Kim Sunley, Senior Employment Relations Adviser, Royal College of Nursing.
Dr Bruce Warner, Dpharm, MRPharmS, Associate Director of National Patient Safety Agency.
Vanessa Whatley, Programme Specialist HCAI, Quality & Saety Team, NHS West Midlands.
Karen Wood, Patient Safety Lead, West London Mental Health NHS Trust.
Vivienne Evans, Communication Officer, Royal College of Nursing.

Confidentiality

The Learning Zone upholds the principles of confidentiality and anonymity. We would like to thank the models, actors and others who allowed their images to be used in this learning area. The scenarios are based on real events however, names and identifiable information of people and places have been changed except for those already in the public domain or where an individual has given permission for the Learning Zone to present a real life account.