Patient Safety

Facilitator's Guide and Outline

Rationale

Minimizing real and potential patient harm through sound patient safety practices is essential for everyone who works in a patient care setting.

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Grabber

L. Leape quote 99% of errors are systems-related, not human failure

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Key Message #1

The scope of medical error is significant, and everyone is vulnerable

  • National data CRICO data
  • Institution data

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The problem has drawn national attention

  • IOM Reports
  • Joint Commission patient safety improvement standards
  • The Leapfrog Group

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Key Message #3

Understanding the problems and solutions related to patient safety requires understanding the concepts behind these terms

  • Adverse event
  • Close call
  • Error
  • Human factors
  • Latent errors
  • Malpractice
  • Medical error
  • Near-miss
  • Negligence
  • Patient safety
  • Potential adverse event
  • Preventable adverse event
  • Risk management
  • System

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Every institution has some common and some unique barriers to optimal patient safety. Understanding those is the starting point for improvement.

Barriers common to all (most) health care settings

  • Basic tenets of human error
  • Accidents waiting to happen
  • Reluctance to report and discuss errors

Barriers unique to your local setting [to be added by instructor]

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Key Message #5

The desired culture for optimal patient safety has these key ingredients

  • Leadership priority
  • Non-punitive reporting
  • Mistakes "elimination" strategies
  • Safer process design
  • Interventions to reduce harm

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Key Message #6

The basics for patient safety improvement efforts

  • Focus attention on high-risk processes
  • Redesign processes so that simple mistakes don't end up harming patients

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Summary

Patient safety is everyone's responsibility. Understanding the problem is the first step toward improvement.

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