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

Step 4: Hazard Analysis

Step 4B. Determine the Severity and Probability of each potential cause. This will lead you to the Hazard Matrix Score. SEVERITY RATING:
Catastrophic Event
(Traditional FMEA Rating of 10 - Failure could cause death or injury)
Major Event
(Traditional FMEA Rating of 7 – Failure causes a high degree of customer dissatisfaction.)
Patient Outcome: Death or major permanent loss of function (sensory, motor, physiologic, or intellectual), suicide, rape, hemolytic transfusion
reaction, Surgery/procedure on the wrong patient or wrong body part, infant abduction or infant discharge to the wrong family
Visitor Outcome: Death; or hospitalization of 3 or more.
Staff Outcome: * A death or hospitalization of 3 or more staff
Equipment or facility: **Damage equal to or more than $250,000
Fire: Any fire that grows larger than an incipient
Patient Outcome: Permanent lessening of bodily functioning (sensory, motor, physiologic, or intellectual), disfigurement, surgical intervention required, increased length of stay for 3 r more patients, increased level of care for 3 or more patients
Visitor Outcome: Hospitalization of 1 or 2 visitors
Staff Outcome: Hospitalization of 1 or 2 staff or 3 or more staff experiencing lost time or restricted duty injuries or illnesses
Equipment or facility: **Damage equal to or more than $100,000
Fire: Not Applicable – See Moderate and Catastrophic
 
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