Embedding human factors and systems thinking in patient safety education: the Contributing factors, Analysis, and Recommendation Education (CARE) Tool.

چکیده اصلی

BACKGROUND: Despite the recognised need, there remains a deficit of professionals skilled in the application of human factors theory and methods in patient safety incident reviews in healthcare. Addressing this gap by embedding human factors theory into quality and safety education is needed to develop professional who can drive sustainable and meaningful patient safety improvement. OBJECTIVE: Develop an educational tool to support graduate students in developing knowledge and skills in the practical application of human factors frameworks to real-world patient safety challenges. METHODS: The tool was iteratively developed and used within a graduate-level human factors course using case-based learning to facilitate a theory-to-practice application. RESULT: We developed the Contributing factors, Analysis, and Recommendation Education (CARE) Tool-a practical, integrated tool designed to support students and professionals in applying human factors theory to complex and real-world patient safety challenges. The CARE Tool combines three human factors frameworks: Systems Engineering Initiative for Patient Safety, Human-Tech Ladder and Hierarchy of Intervention Effectiveness (HIE). The CARE Tool's primary use is to guide users through a structured patient safety incident review process grounded in systems thinking. In this paper, we describe the development and use of the tool by a group of interdisciplinary students during a graduate-level course in human factors. CONCLUSION: The CARE Tool was designed to facilitate practical understanding of human factors principles. Importantly, the CARE Tool contributes to addressing the need to develop professionals who can embed systems thinking into patient safety incident review methods. Beyond the classroom, the tool may be used by those analysing incidents in healthcare settings and/or developing mitigations.

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