Crossing the Quality Chasm: A New Health System for the 21st Century ... care we have and the health care we could have lies not just a gap but a chasm. ...
Held at UM Towsley Center 11/22/02. Webcast to ten sites around state. Registrants = 195 ... Transformation of Root Cause Analysis learning into gains in ...
Multi-Departmental Experience. Leadership Skills. East Alabama Medical Center ... Safety Boot. Camp. Human Factor Engineering. Design reliability into processes ...
Follow five 'Rules' of thumb (heuristics) for developing root cause statements. 5/8/09 ... Practical rules of thumb. If you're not sure its safe, it's not safe ...
... can experience a medical error during a 3-4 days ... SAFETY Human error is not the primary cause of harm. It is the system that allowed the harm ...
Do I 'know' that hash browns are not included in the Original Grand Slam Breakfast? ... But getting back to the hash-brown potatoes, I should 'know' that they ...
collect and analyse information through a national reporting and ... Streamline reporting (MHRA, SUIs, local) Future Proposal for Patient Safety Action Teams ...
Aging population & polypharmacy. Lack of integration of clinical pharmacy services ... Reduces Inappropriate Use of Polypharmacy Better Medication Management ...
... by individuals and organizations to protect health care recipients from being ... Auto-shut off heating devices. Circuit breakers. Ready-to-administer medications ...
Peninsula College of Medicine and Dentistry. Scottish Clinical Skills Network ... Haptic/VR simulators. 1950 1960 1970 1980 1990 2000. Resuscitation movement ...
1. Creating a Culture of Patient Safety. WVU Department of ... Non-putative, can be filed anonymously. 15 ... Non-putative focus on systems-based analysis ...
University of Michigan (many times/year) ... Make sure you know your VA or university 'rules' ... Cross-sectional Study of M&M conferences in 4 hospitals ...
... errors than from breast cancer, AIDS, or car accidents ... Receiver reviews relevant historical patient data including: Previous care. Previous treatment ...
Identify processes for Medical Staff acceptance and support with Red Rules ... always confirm patient identity using at least two hospital approved identifiers ...
Human Factors Engineering and Patient Safety Faculty Development ... Knee-jerk vs. HFE-based Remedy. Make 'sure' to use the correct color Adaptor!? Better ...
The Scottish Patient Safety Paediatric Programme, General Ward Workstream Jane Murkin, National Co-ordinator Annette Henderson PM NHS Lothian Aims Complexity and ...
Overview of the Role and Responsibilities of the Patient Safety Officer The Quality Colloquium at Harvard ... Analysis of near-misses reveals the following ...
Patient Safety Interventions John Gosbee, MD, MS VA National Center for Patient Safety John.Gosbee@med.va.gov www.patientsafety.gov Adapted from John Gosbee, MD, MS
Title: Slide 1 Author: Mary Beth Privitera Last modified by: Craig Froehle Created Date: 4/6/2005 2:44:19 AM Document presentation format: On-screen Show
Using the Mortality and Morbidity Conference to Improve ... There is some opportunity for absolution. Insight: The 'Aha!' Moment. Full discovery of facts ...
Overview of the Role and Responsibilities of the Patient Safety Officer The Quality Colloquium at Harvard 21 August 2005 Douglas B. Dotan, MA, CQIA (ASQ)
Our Aim ... other than words such as gestures and facial expressions. ... the WRITTEN sign-out wasn't as good as it could have been? 54. Errors in Communication ...
'Patients will be helped to navigate the maze of health information through the ... 1150 people/year in recent contact with mental health services commit suicide ...
Nurse leaders must have the competencies necessary to design, coordinate and ... If you're a nurse that's really busy and you're waiting for one med to come, you ...
S Conroy, C North, T Fox, L Haines, C Planner, P Erskine, I Wong, H Sammons. Arch. Dis. ... H, Thurm CW, Suresh G, Gray JE, Edwards WH, Goldmann D, Classen ...
Is quality safety? Is safety quality? Clarity is a priority. Sam Sheps Karen Cardiff Department of Health Care and Epidemiology University of British Columbia
The idea that medical errors are caused by bad systems is a transforming concept ... Preoperative verification wrong site. Mark your site with patient ...
Aging population - polypharmacy. ADEs leading cause of death and injury IOM Report ... Polypharmacy. 9. HIV/AIDS. 10. Multiple chronic conditions. 15 ...
Conflating the concepts may implicitly create the belief that if you enhance ... to achieve safety you lose focus on safety if you conflate it with quality ...
An Organisation with a Memory, which looked at learning from adverse incidents ... for contractors, concern over providing a dossier of their own incompetence' ...
Beth Israel Deaconess Medical Center. Contemporary OB/GYN (Sexton, 2006) ... Memorial did it, so it doesn't take a big academic medical center,' Leape says. ...
University of Michigan Hospitals and Health Centers. AkkeNeel Talsma, PhD, RN ... Sparrow, Lansing. Spectrum East, Grand Rapids. St. Johns, Detroit ...
Title: Unit Based Hazard Assessment Subject: Facility Champion Training Author: VISN 8 Patient Safety Center of Inquiry Keywords: patient safety, safe patient ...
Gar Williams. Lorenzo Brown. Jason Wells. Jay Perez. Marla Silliman. Michelle Skubick. Sheryl Dodds. Sy Saliba. What we said in July... Starts with Mission ...
This presentation, provided by the Indiana Association of Air Medical Services ... a gurney to move patients while others have their own portable stretcher system. ...
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