Table 1

Comprehensive Unit-Based Safety Programme*

1. Science of safety training
  • Deliver through interactive discussions with staff

  • Four learning objectives

2. Safety hazard identification
  • Ask unit staff ‘how the next patient will be harmed’

  • Look at other sources to identify unit-based hazards (eg, event reporting system, liability claims, sentinel events)

  • Coach and team leader assemble list of hazards

  • Team prioritises hazards that pose greatest risks using group consensus

3. Senior executive partnership32
  • Executive meets with team and other unit staff monthly

  • Executive facilitates resources and political support for risk-reduction interventions

  • Executive holds team accountable for mitigating hazards

4. Learn from defects33
  • Team trained to use tool to investigate and learn from defects (problem-solve)

  • Learn from one defect per month

  • Measure of learning is a written summary of what happened, why it happened, what was done to reduce risk and how they know risk was actually reduced

5. Communication and teamwork focus
  • Coach discusses ways to improve unit culture and communication

  • Team implements tools to improve communication and teamwork

  • Several tools available for use and/or modification34–38

  • * A full description of Comprehensive Unit-Based Safety Programme has been published.24

  • Hospital-wide training also done (described below); presentation available online (