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 5: Failure to Act is Only Causal When There Is a Pre-Existing Duty to Act.

  • WRONG: The nurse did not check the STAT orders every half hour.
  • CORRECT: The absence of an established procedure for nurses to check the STAT orders on the printer created the vulnerability that urgent orders would not be administered; this resulted in the BOLUS of antibiotics not being administered.
 
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