Patient Safety: A Toolkit for Educators

Alissa Craft, DO, MBA AACOM Scholar in Residence

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

Plugging the Holes in the Cheese

VA NCPS

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

Reason

Burke J. Infection control-a problem for patient safety. New Eng Journal of Medicine

Infections

The Course Evaluation

“In God we trust, all others must bring data!”

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