Quality and Safety

Adverse Events

Adverse events are injury due to medical or surgical treatment and can be divided into
- preventable adverse event
  - those injuries that could have been avoided if accepted practice or protocols had been followed
- non-preventable adverse event
  - those injuries that could not have been avoided even with optimal medical care
Sentinel event
- any unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof
- requires immediate investigation, discovery of the cause, and response
Near miss
- potential adverse event that could have caused harm but did not
- provide opportunities for developing preventive strategies and action
Malpractice
improper, negligent, or illegal activity by a medical practitioner

Human Factors Design

Forcing function
- a method to prevent undesirable results by forcing the optimal choice as default
  - e.g., setting a default prescription length for medications that are prone to abuse
- this is the most effective intervention in human factor design
Standardization
- a method to increase process reliability
  - e.g., having a checklist
Simplification
- a method to decrease wasteful activities
electronic medical record consolidation

Safety Culture

A safe environment where people can express their safety concerns without fear of negative consequences
Prevention of wrong-site, wrong-procedure, or wrong-patient surgery
- Joint Commission Universal Protocol
  - Conduct a pre-procedure verification process
  - Mark the procedure site
Perform a time-out

PDSA cycle