Patient Safety and Quality Improvement
 Modules  Module 2: History of Patient Safety/Clinical Quality Improvement
1. Introduction to Course
2. History of Patient Safety
3. The Science of Human Error
4. The Analysis of Medical Error
5. Evidence-Based Medical Practice
6. Communication and Information Transfer
7. Adverse Patient Outcomes
8. The Role of the Patient and Family
9. Environmental Safety in the Medical Setting
10. Safe Medical Practice In Ambulatory Settings

The “End Results” System

  • Proposed that surgeons track all patient outcomes following surgery (for at least one year), and publish (or otherwise make available to all patients and the public) those results
  • Not well-received by his colleagues at the MGH
    • Thrown off MGH Medical Staff
    • Established own hospital, based upon “The End Results System”
    • Eventually re-admitted to MGH Medical Staff (and Codman hospital closed)
 
 
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