Human Factors and Learning from Incidents

This course explains why skilled and caring professionals make errors, using the science of human factors, the Swiss cheese model and the idea of a just culture. It shows how NHS organisations learn from patient safety incidents, how you can design safer ways of working, and how to use these ideas to write a reflection and remediation plan with real insight.

What you will learn

• Define human factors and explain how the person, the task, the tools, the environment and the organisation interact to produce safe or unsafe care.
• Use the Swiss cheese model and the distinction between active failures and latent conditions to analyse an incident.
• Distinguish between slips, lapses, mistakes and violations, and explain why each needs a different response.
• Describe how the Patient Safety Incident Response Framework and a just culture approach support learning in the NHS in England.
• Apply practical human factors tools, such as checklists, structured communication and the hierarchy of controls, to improve safety.
• Write a reflection and remediation plan that balances personal accountability with understanding of system factors.

Course content

1. Why human factors matters (2 min)
2. The system around the person (3 min)
3. Why skilled people make errors (3 min)
4. The Swiss cheese model (2 min)
5. Learning from incidents in the NHS (3 min)
6. Designing safer systems (2 min)
7. Case study, reflection and remediation (4 min)
8. Knowledge check (10 questions, 10 min)
9. Guided reflection (15 min)

Standards and guidance covered

• GMC: Good Medical Practice (2024), including the duties to contribute to patient safety, report incidents and be open when things go wrong
• NMC: The Code (2015, updated 2018), including the sections on preserving safety and being open and candid
• HCPC: Standards of conduct, performance and ethics (2024), including the standards on managing risk and reporting concerns about safety
• GPhC: Standards for pharmacy professionals (2017), including speaking up when things go wrong
• NHS England: The NHS Patient Safety Strategy (2019) and the Patient Safety Incident Response Framework (2022)
• NHS England: A just culture guide

Certificate

Courses are free to study. When you pass the knowledge check (80%) and complete your reflection, you can buy a verified certificate showing your CPD time, with a unique ID and QR code that anyone can check on our verification page.

Related guides

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Medication Error Reflection: A Worked Example for Nurses

A medication error reflection example for nurses: what to do first, how to structure your reflection, a weak vs strong version, and how to show real learning.

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Duty of Candour: What to Do When Things Go Wrong

Duty of candour explained for UK healthcare professionals: what to do when things go wrong, how to apologise, near misses and the statutory duty.

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Human Factors in Healthcare: The Swiss Cheese Model With Examples

The Swiss cheese model in healthcare explained with clinical examples: active failures, latent conditions, human factors and how to use it in a reflection.

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Practitioner Insight is an independent education provider. It is not affiliated with or endorsed by the GMC, MPTS, NMC, HCPC, GPhC or any NHS organisation, and this information is not legal advice. If you have been referred to a regulator, speak to your defence organisation, trade union or legal representative.