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Del curso dictado por Johns Hopkins University

Patient Safety and Quality Improvement: Developing a Systems View (Patient Safety I)

228 calificaciones

Johns Hopkins University

Patient Safety and Quality Improvement: Developing a Systems View (Patient Safety I)

228 calificaciones

Curso 1 de 7 en SpecializationPatient Safety

In this course, you will be able develop a systems view for patient safety and quality improvement in healthcare. By then end of this course, you will be able to: 1) Describe a minimum of four key events in the history of patient safety and quality improvement, 2) define the key characteristics of high reliability organizations, and 3) explain the benefits of having strategies for both proactive and reactive systems thinking.

De la lección

Definitions in Patient Safety and Quality Improvement: An Overview

In this module, you will be reviewing several key terms and tools that are used in patient safety and quality improvement. This will allow you to begin to develop the common language used among patient safety and quality improvement experts and practitioners. By the end of this module you will be able to: 1) differentiate between the terms harm, hazard, error and risk within a patient safety and quality improvement framework, 2) describe how quality and safety overlap and how they are different and 3) differentiate between root cause analysis and a failure mode and effects analysis.

Definitions and Intersection of Quality and Safety3:36

Sentinel Event1:52

Root Cause Analysis (RCA)5:27

Failure Mode and Effects Analysis (FMEA)7:54

Conoce a los instructores

Melinda Sawyer
Director, Patient Safety
Armstrong Institute for Patient Safety

Okay, the next topic is on error.

Now, when you hear somebody use the term error,

you should always make sure you understand what they mean by

the word because there's no uniformly agreed upon definition of error.

The one on your screen I like in particular and it's by

actually the Institute of Medicine and they've defined an error as: "The

failure of a planned action to be completed as intended (an error of

execution) or the use of a wrong plan to achieve an aim (an error of planning)."

That's actually based on James Reason's work,

but I think this is the nicest definition,

most comprehensive definition I've come across.

There's a number of different ways in which error is used.

The first one I'll talk about is a close call or a near miss.

And that actually is used two different ways.

One is the error didn't reach a patient.

So as an example, a pharmacy technician makes the wrong medicine,

and a pharmacist spots that that error was made and stops it from being

dispensed out to the floor so it can't be administered to a patient.

So that was an error,

but it didn't reach the patient.

Another near miss is when an error reaches the patient with

the potential of causing significant harm and doesn't.

So that, too, would be categorized as a near miss.

Now there's also two other different ways of thinking about error,

and those are errors of commission and errors of omission.

So the first, errors of commission,

those are a mistake that consists of doing something wrong.

So for instance, I intend to give medicine to one patient,

but accidentally give it to another patient.

Here are some examples,

so I gave the wrong drug,

I gave the medicine to the wrong patient, or,

I performed the wrong procedure on a particular patient.

Those would be errors of commission.

Interestingly when you're reading about errors and error rates,

typically this is the kind of error that they're talking about.

Generally, they don't talk about errors of omission,

but errors of omission can be just as significant as an error of commission.

So an error of omission is a mistake that

consists of not doing something that should have been done.

Here's some examples, failing to order prophylactic therapy

to prevent venothromboembolis when it was indicated,

that would be an error of omission.

Another example of an error of omission would be failing to assess for pregnancy

before administering an abdominal X-ray to a woman.

I now want to compare this concept of error and harm.

Real important to remember that not all errors cause harm,

and not all harm is caused by errors.

So in this Venn diagram,

let's first look at those population of errors that didn't cause harm.

In the center, these errors caused preventable harm.

It's preventable because it was secondary to an error.

And then other harm that's not associated with an error is considered unavoidable.

What we should do is target preventable harm.

That really should be our key goal

in our safety projects and our performance improvement projects,

is to prevent preventable harm.

Now, obviously we want to decrease the number of errors that are made,

but humans will always make errors because after all,

to err is human.

So our main goal should be to avoid preventable harm.

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