Course: Patient Safety and Medical Errors

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Lecture Materials

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» Lecture 1: Science of Safety (Wu and Pronovost)

  • Discuss and distinguish individual and system factors that cause accidents
  • Recognize the contribution of human factors to error causation

» Lecture 2: Adverse Events and Safety: Concepts and Definitions (Morlock, Wu)

  • Synthesize the key points found in seminal reports

» Lecture 3: The IOM Report(s) (Wu)

  • Synthesize the key points found in seminal reports

» Lecture 4: Safety and Medicine (Pronovost)

  • Evaluate the evidence that medical errors are a leading cause of death and injury

» Lecture 5: Systems of Influence (Morlock)

  • Describe how four systems of organizational influence affect patient safety

» Lecture 6: Safety Culture at Work: Addressing Safety Culture Provides the Lubrication That Makes System Change Possible (Sexton & Wu) - Not Yet Available

  • Recognize the value of caregiver culture assessments in quality improvement efforts
  • Learn that safety culture is valid, related to outcomes, and responsive to interventions
  • Learn the methodological rigor of collecting, interpreting, feeding back, and using safety culture data

» Lecture 7: Playing in the Sandbox: Teamwork Climate, Situational Awareness, and Communication (Sexton, Wu) - Not Yet Available

  • Review the dynamics of teamwork, communication, and measurement
  • Explore the usefulness of measuring these variables to assess and improve safety

» Lecture 8: Measuring Patient Safety (Pronovost, Wu)

  • Recognize some of the challenges to measuring patient safety
  • Explain an approach to measuring aspects of safety in clinical practice

» Lecture 9: Adverse Event Reporting Systems (Morlock, Wu)

  • Discriminate between voluntary and mandatory reporting systems
  • Synthesize the lessons that aviation reporting systems have for medical reporting
  • Recognize the characteristics of successful reporting systems
  • Describe an example of ICU reporting
  • Describe an application of hospital reporting systems

» Lecture 10: Reporting Medical Errors: Real-Time Tales (Miller, Wu)

  • Describe a widely used voluntary incident reporting system
  • Discuss the strengths and limitations of such a system

» Lecture 11: Investigating a Defect (Pronovost)

  • Describe the techniques for investigating adverse events
  • Identify the system factors that lead to a medical error
  • Identify the relationship between active failures and latent failures

» Lecture 12: Interventions to Improve Patient Safety (Wu, Morlock)

» Lecture 13: Practical Tools to Improve Patient Safety (Pronovost)

  • Describe how a comprehensive unit-based safety program is conceptualized and implemented

» Lecture 14: CUSP: Designing a Comprehensive Unit-based Patient Safety Program (Wu, Pronovost, and Engineer)

  • Describe how policy, payment, accreditation, and education can contribute to safety
  • Analyze websites of national patient safety and quality organizations

» Lecture 15: Medication Safety (Wu, Morlock)

  • Provide a four-stage conceptual model for medication safety initiatives at the facility level
  • Discuss at a conceptual level the multiple steps of an adverse event reporting system as applied to medication errors
  • Analyze examples of different types of medication errors that have been reported to the MEDMARX system, including errors in post-anesthesia care units (PACUs) and errors associated with infusion-related medication administration

» Lecture 16: Disclosure of Adverse Events and Medical Errors (Wu)

  • Discuss the argument for disclosure of adverse events to patients
  • Identify components of a good disclosure discussion

» Lecture 17: The Joint Commission and Patient Safety (Bundy)

» Lecture 18: Macrosystems: Policy, Payment, Regulation, Accreditation, and Education to Improve Safety (Wu, Morlock)

  • Describe how policy, payment, accreditation, and education can contribute to safety
  • Examine Web sites of national patient safety and quality organizations

» Lecture 19: Safety in Surgery: What's the Data (Makary) - Not Yet Available

» Lecture 20: Adverse Events in the Outpatient Setting (Morlock, Wu)

» Lecture 21: An Overview of the Patient Safety Programme at WHO (Wu & Engineer)

» Lecture 22: Clean Care is Safer Care (Engineer & Wu)

» Lecture 23: Overview of STOP-BSI Program (Pronovost & Wu)

» Lecture 24: Where Are We Now? (Wu)

  • Identify changes in the safety of United States health care since the first IOM report