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

NCPS RCA/HFMEA Action Hierarchy

Stronger Actions
  • Architectural/physical plant changes
  • New devices with usability testing before purchasing
  • Engineering control or interlock (forcing functions)
  • Simplify the process and remove unnecessary steps
  • Standardize on equipment on process or caremaps
  • Tangible involvement and action by leadership in support of patient safety
Intermediate Actions
  • Redundancy
  • Increase in staffing/decrease in workload
  • Software enhancements/modifications
  • Eliminate/reduce distractions (sterile medical environment)
  • Checklist/cognitive aid
  • Eliminate look- and sound-alikes
  • Readback
  • Enhanced documentation/communication
Weaker Actions
  • Double checks
  • Warnings and labels
  • New procedure/memorandum/policy
  • Training
  • Additional study/analysis

Medicine bottles

 
Copyright © University of New Mexico
Health Sciences Library and Informatics Center
Learning Design Center