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

Rule 4. Identify the Preceding Cause(s) of Procedure Violations.

  • Procedural violation (not following rules) can not be directly managed
  • The cause of the procedural violation can be directly managed
  • Violating a procedure is often because of a local norm (group expectation)
  • Address the incentives that created the norm.
  • WRONG: The techs did not follow the procedure for CT scans.
  • CORRECT: Noise and confusion in the prep area and production pressures to quickly complete CT scans increased the probability of missing steps in the CT scan protocol; this resulted in an air embolism by inadvertent use of an empty syringe.
 
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