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Medical Error
Failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.
Kohn LT et al. To Err is Human. 1998
The Opportunity
Current Annual Level Benefit with a 50% Cut Benefit with a 90% Cut
974,000 Injuries 487,000 Avoiding Injury 877,000 Avoiding Injury
44,000 – 98,000 Deaths 22,000-49,000 Lives Saved
39,600 – 88,200 Lives Saved
$17 - $29 Billion in Costs $8.5 - $14.5 Billion Saved $15.3 - $26.1 Billion Saved
Medical Errors in US Hospitals
The Toolkit Format
Contains all the information one needs to implement a program – in one place, ready to use.
The Content
The Pre-Assessment
The Objectives
The Lesson Plans
The Toolkit Evaluation
References and Resources
The Pre-Assessment
A written or on-line multiple choice test of the areas to be covered in each lesson plan.
Approximately 3-4 questions per lesson.
As with any improvement opportunity, the goal is always to achieve 100%.
The Lesson Plans
What Is Patient Safety and Why Is It Critical?
What Are Human Factors? How Do They Impact Safety?
Systems Practice: The Chef and The Cookbook
Learning from Errors
Learning Before Errors
Patient Safety Applied Reducing Infection Medication Errors
Swiss Cheese Model
Why do interns make prescribing errors? A qualitative study MJA 2008; 188 (2): 89-94 Ian D Coombes, Danielle A Stowasser, Judith A Coombes and Charles Mitchell Adapted from Reason’s model of accident causation
Human Factors
Teams
Effective teams possess the following features: o a common purpose
o measurable goals
o effective leadership and conflict resolution
o good communication
o good cohesion and mutual respect
o situation monitoring
o self-monitoring
o flexibility
References and Resources Reason JT. Human error. Reprinted. New York: Cambridge University Press, 1999.
Reason JT. Managing the risks of organizational accidents, 1st ed. Aldershot, UK, Ashgate Publishing Ltd, 1997.
Runciman B, Merry A, Walton M. Safety and ethics in health care: a guide to getting it right, 1st ed. Aldershot, UK, Ashgate Publishers Ltd, 2007.
Vincent C, Safety. P. Patient Safety, Edinburgh, Elsevier, 2006.
Emanuel L et al. What exactly is patient safety? A definition and conceptual framework. Agency for Health Care Quality and Research, Advances in Patient Safety: from Research to Implementation, 2008 (in press).
Making health care safer: a critical analysis of patient safety practices. Evidence Report/Technology Assessment, No. 43, AHRQ Publication No. 01-E058. Rockville, MD, Agency for Healthcare Research and Quality, July 2001 (http://www.ahrq.gov/clinic/ptsafety/summary.htm).
Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. Washington, DC, Committee on Quality of Health Care in America, Institute of Medicine, National Academy Press, 1999 (http://psnet.ahrq.gov/resource.aspx?resourceID= 1579).
Crossing the quality chasm: a new health system for the 21st century. Washington, DC, Committee on Quality of Health Care in America, Institute of Medicine, National Academy Press, 2001