The majority of medical errors do not result from individual recklessness or the actions of a particular groupthis is not a bad apple problem. More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fault to prevent them. (p. 2)
To achieve a better safety record, the report recommends a four-tired approach:
Establish a national focus to create leadership, research, tools, and protocols to enhance the knowledge based about safety. (a Center for Patient Safety)
Identify and learning from errors by developing a nationwide public mandatory reporting system and by encouraging health care organizations and practitioners to develop and participate in voluntary reporting system
Raising performance standards and expectations for improvements in safety through the actions of oversight organizations, professional groups, and group purchasers of health care (Licensing, certification, accreditation)
Implementing safety systems in health care organizations to ensure safe practices at the delivery level. (a culture of safety; well-understood safety principles, such as designing jobs and working conditions for safety; standardizing and simplifying equipment, supplies, and processes; and enabling care providers to avoid reliance on memory.)
Institute of Medicine (IOM). (1999, November). To err is human: Building a safer health system.
In Week 4, you learned to identify forces that encourage or impede efforts to improve quality. In addition, you learned hospital leaders may be encouraged to build a framework that enables the organization to deliver health service with a clearer picture of healthcare quality. This week we will look at a realistic scenario involving patient safety.
The reading materials for Week 5 are Chapters 12 & 13 from Applying quality management in healthcare by Spath & Kelly (2017).
The Learning Objectives for Week 5:
Apply cost benefit analysis in assessing process and outcomes in patient care.
Articulate and apply various quality management tools utilized to monitor and enhance patient safety and clinical quality.
Develop and assess a quality management plan.
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