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

Computers Will Fix Things?

  • ISMP survey & analysis of 307 pharmacy computer systems
  • 10 test cases of drug-drug interactions and other unsafe medication orders
    • From “easy to detect” to “hard to detect”
  • Only FOUR passed all 10 tests
  • Reasons were many
    • Hard-to-use human-computer interfaces
    • Unrealistic resources allocated to properly maintain and use the systems
 
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