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

Outcomes Measurement

  • Process measures
    • Easiest, but weakest
    • Example: measure that the door handle was replaced
  • Vulnerability (indirect) measures
    • Harder to do, but stronger
    • Example: measure percent of technicians are less confused
  • Close call or adverse event measures
    • Hardest, but the gold standard
    • Example: measure per cent of “code teams” that go to the wrong place
 
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