Patient Safety

Support Materials

Slide Presentation

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References

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  1. Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press, 1999.
  2. Perrone J. Designing a safer, smarter health care system: AMA foundation looks at ways to prevent mistakes. American Medical News. Oct. 27, 1997.
  3. Leape LL, Lawthers AG, Brennan TA, Johnson WG. Preventing medical injury. QRB Qual Rev Bull 1993; 19: 144-49.
  4. Committee on Quality of Health Care in America, Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy Press, 2001.
  5. JCAHO 2003 National Patient Safety Goals
  6. Leapfrog
  7. National Patient Safety Foundation: Patient Safety Definitions
  8. Leape LL. Error in medicine. JAMA 1994; 272: 1851-57.
  9. Reason J. Human Error (NY: Cambridge Press, 1990).
  10. Reason J. Managing the Risks of Organizational Accidents (Brookfield, VT: Ashgate, 1997).
  11. Patient safety: a call to action. Medscape General Medicine. 2001;3(1)

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Facilitator's Guide and Outline

A full outline of the key messages for this module, including links to slides, references, and facilitation tips.

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Facilitation Tips

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  1. Icebreaker

    Ask the group for examples of patient safety problems they have seen in their professional life or experienced as patients in the last year. Note them and use them as examples when describing types of human factors or systems errors that might have contributed to the outcomes the group mentioned.

  2. Data

    CRICO and Institutional data related to medical errors can be provided by your institutions risk manager or by contacting RMF.

  3. Definitions

    Ask participants to define these terms in relation to their particular responsibilities. What is a "close call" for a resident may be different than for a nurse, or for a lab technician. Seeing how the "real" meaning changes from person to person can set the stage for a discussion about the need to establish common mental models.

  4. Barriers

    Having participants generate a list of the barriers they encounter is an excellent opportunity to make this module more practical than theoretical.

  5. Application

    Ask participants to volunteer how they might use this introduction to patient safety to reduce the potential for harm to the patients they are involved with.

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