Domain 5 Lesson Plan(s)

Optimize Human and Environmental Factors

Teaching methodologies: Click on links for teaching material

Introductory 1 or 2 hour interactive, seminar format:

• Present Ben Kolb's case  and have residents identify issues related to the case
• Show the Beyond Blame video - available at ISMP Online Store for $45.00
• Use the Ben Kolb Facilitator's Guide to return to the case and help identify issues and related competencies

Seminar 1 hour:

• Use Human Factors slide deck to explain the basics of the impact of human factors
• Pre or post session read Reason's article Qual Saf Health care 1995
• Facilitate a discussion on faculty and residents' experiences in their personal /professional/work environment; demonstrate using a piece of Equipment e.g. epipen and how mistakes can be made.

Journal club 1 hour:

• Use article below re sleep references and critique article
• Facilitate a discussion of fatigue issues, residents' experiences in how this might affect performance
  • Lockley et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. NEJM 2004Oct28;351(18):1829-1837.
  • Landrigan et al. Effect of reducint interns' work hours on serious medical errors in intensive care units. NEJM 2004Oct28;351(18):1838-1848.
  • Landrigan et al. Interns' compliance with accreditation council for medical education work-hours limits. JAMA 2006Sept6;296(9):1063-1070.
  • Lockely et al. Effects of health care provider work hours and sleep deprivation on safety and performance. Jt Comm J Qual patient  safety 2007 Nov;33(11 Suppl):7-18.
  • Landrigan et al. Effective implementaiton of work-hour limits and systemic improvements. Jt Comm J Qual patient  safety 2007 Nov;33(11 Suppl):19-29.
  • Fahrenkopf AM et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ. 2008 Mar1;336(7642):488-491.
  • Janney M, Landrigan C. Improving nurse working conditions: towards safer models of hospital care. J Hosp Med. 2008 May:3(3):181-183.
  • Landrigan et al. Effects of the accreditation council for graduate medical education duty hour limits on sleep, work hours, and safety. Pediatrics 1008Aug;122(2):250-258.
  •  Volpp KG, Landrigan CP. Building physician work hour regulations from first principles and best evidence. JAMA. 2008 Sep 10;300(10):1197-1199

Other Resources

• Misread Label Case Study - IHI Open School - Available at IHI Website - YOU MUST REGISTER WITH OPEN SCHOOL
• Lesson learned from aviation and other industries "Human Error" (PowerPoint)