Updated: 2/12/2022

Quality and Safety

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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
  • A method to test change in the clinical setting 
    • Plan
      • define what is the problem and the desired solution
    • Do
      • test the new process
    • Study
      • measure and analyze the data generated
    • Act
      • integration
    • mnemonic: "PDSA"

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