Patient Safety and Quality Improvement
 Modules  Module 3: The “Science” of Human Error
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

Systems Analysis of Adverse Drug Events

  • Sixteen “systems failures” identified – 7 caused 78% of errors
    • Drug knowledge dissemination
    • Dose and identity checking
    • Patient information availability
    • Order transcription
    • Allergy defense
    • Medication order tracking
    • Interservice communication
    • Leape, 2005
 
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