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"