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Quality Improvement and Patient Safety Forum

Quality Improvement and Patient Safety Forum. This is a peer review document subject to the confidentiality requirement of the New Mexico Review Organization Immunity Act, NMSA §1978 41-9-5 (2003).  Unauthorized disclosure is strictly prohibited and subject to fines. Objectives.

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Quality Improvement and Patient Safety Forum

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  1. Quality Improvement and Patient Safety Forum

  2. This is a peer review document subject to the confidentiality requirement of the New Mexico Review Organization Immunity Act, NMSA §1978 41-9-5 (2003).  Unauthorized disclosure is strictly prohibited and subject to fines.

  3. Objectives • Perform asystem-based root cause analysis • Identify one system-level intervention to offer to leadership

  4. Last time on QIPSF…

  5. The Outcome

  6. What were the costs or potential costs of of this adverse outcome?

  7. Systems-Based Root Causes? People Policies Outcome Process Place

  8. RCA Discussion

  9. Potential Systems-Level Interventions?

  10. Potential Systems-Level Interventions?

  11. Effort vs Yield? Yield Effort

  12. Our Suggested Interventions? • Ideally 1 suggestion for clinical leadership

  13. Objectives • Perform a system-based root cause analysis • Identify one system-level intervention to offer to leadership

  14. References • Szostek, Jason H., et al. "A systems approach to morbidity and mortality conference." The American journal of medicine 123.7 (2010): 663-668.

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