Patient Safety and Quality Improvement
 Modules  Module 4: The “Analysis” of Medical Error, and Implementation
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

Tools for Analysis of Errors

  • “Root Cause” Analysis
    • Retrospective analysis of a significant adverse outcome or “near miss” (sentinel event)
  • “Failure Mode and Effects” Analysis
    • Prospective analysis of a work process to determine the possible ways it can perform poorly (cause harm), and by this analysis develop means to reduce the risk of such occurrences, and to control the damage/speed the recovery from such events if and when they occur
 
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