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Patient Safety Curriculum September 12, 2008

Patient Safety Curriculum September 12, 2008. Definitions. "A medical error is anything that happened in my office that shouldn’t have happened and that I absolutely do not want to happen again.“ AAFP Past President Bruce Bagley, MD

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Patient Safety Curriculum September 12, 2008

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  1. Patient Safety Curriculum September 12, 2008

  2. Definitions "A medical error is anything that happened in my office that shouldn’t have happened and that I absolutely do not want to happen again.“ AAFP Past President Bruce Bagley, MD “Error is defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim." IOM

  3. What causes medical error? James Reason has categorized errors according to two types of causes: active failure and latent conditions. Active errors can take the form of slips (doing a familiar action in the wrong way), lapses (failures of memory such that planned actions do not happen), and mistakes (errors in reasoning that lead to wrong choices). Latent conditions are the systemic properties, or root causes, that lead to errors. These might include system interfaces, or poor maintenance or management practices. In situations with latent conditions, if an individual errs he/she has, in a sense, been set up to fail by the environment.

  4. Audit of the UFCD Curriculum • Clinic Procedure Manual • MISSION AND VISION OF THE COLLEGE • STANDARD OF PATIENT CARE • PROTOCOL FOR MANAGING CLINIC MEDICAL EMERGENCIES • PATIENT INFORMATION AND PATIENT CARE • FEES AND COLLECTIONS • GENERAL CLINIC PROTOCOL • GUIDELINES AND POLICY REGARDING THE USE OF IONIZING RADIATION • POLICY FOR SUSPENSION OF DENTAL STUDENTS FROM CLINICAL ACTIVITIES • INFECTION CONTROL DOCUMENT • INFECTIOUS DISEASE POLICY • STERILIZATION, DISINFECTION, AND HAZARDOUS WASTES

  5. Audit of UFCD Curriculum • Quality Assurance Manual • UFCD QUALITY ASSURANCE AND COMPLIANCE PROGRAM • ASSESSMENT TOOLS • STANDARDS OF CARE • STANDARDS OF CARE MATRIX • V. SUMMARY OF UFCD QUALITY ASSURANCE AND COMPLIANCE MANUAL ABBREVIATIONS AND TERMINOLOGY

  6. Clinical Occurrences Types of Occurrences at UFCD (October 2007-May 2008) 82% "medico-legal" or improper/inadequate written documentation. 19% of the total Risks ID'd were medical emergencies 26% were Unplanned escalation of care 15% were unanticipated/unscheduled dental appts

  7. HSC Collaboration Develop a patient safety/medical errors case for IFH. Develop patient safety/medical errors cases for small group discussions within colleges. Develop an online training/quiz for providers and students. Use this FLC to periodically review QA data and address system interfaces or management practices.

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