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Systems-based practice (including health systems, public health, community, schools) and patient safety (including basic concepts and terminology)
Characteristics of a complex system and factors leading to complexity: how complexity leads to error
Sociotechnical systems: systems engineering; complexity theory; microsystems
Health care/organizational behavior and culture:
environmental factors, workplace design and process;
staffing;
overcommitment, space, people, time, scheduling;
standardization, reducing variance, simplification, metrics; safety culture; integration of care across settings; overutilization of resources (imaging studies, antibiotics, opioids); economic factors
Quality improvement
Improvement science principles
Variation and standardization: variation in process, practice; checklists, guidelines, and clinical pathways
Reliability
Specific models of quality improvement: model for improvement: plan-do-study-act (PDSA), plan-do-check-act (PDCA); Lean, including recognition and types of waste; Six Sigma
Quality measurement Structure, process, outcome, and balancing measures Measurement tools: run and control charts Development and application of system and individual quality measures: core measures; physician quality report system (PQRS); event reporting system
Strategies to improve quality Role of leadership Principles of change management in quality improvement: specific strategies
Attributes of high-quality health care High-value/cost-conscious care: overutilization of resources, including diagnostic testing, medications Equitable care: access Patient-centered care Timely care
Patient Safety
Patient safety principles
Error categorization/definition: active vs latent errors; Swiss cheese model of error; preventable vs non-preventable; near miss events/safety hazards
Causes of error
Patient factors: understanding of medication use; health literacy; economic status; cultural factors (eg, religion); failure to make appointments; socioeconomic status Physician factors: deficiency of knowledge; judgment errors; diagnostic errors; fatigue, sleep deprivation; bias – cognitive, availability, heuristic, anchoring, framing Human factors (eg, cognitive, physical, environmental)
High reliability of organization (HRO) principles: change management and improvement science; conceptual models of improvement
Reporting and monitoring for errors: event reporting systems
Communication with patients after adverse events (disclosure/transparency)
Specific types of error
Transitions of care errors (eg, handoff communication including shift-to-shift, transfer, and discharge): handoffs and related communication; discontinuities; gaps; discharge; transfers
Medication errors
Ordering, transcribing, dispensing, administration (wrong quantity, wrong route, wrong drug)
Medication reconciliation Mathematical error
Procedural errors
Universal protocol (time out); wrong patient; wrong site; wrong procedure Retained foreign bodies Injury to structures: paracentesis; bowel perforation; thoracentesis; pneumothorax; central venous/arterial line injuries; arterial puncture and bleeding and venous thrombosis; lumbar puncture bleeding; paralysis Other errors: anesthesia-related errors; mathematical errors
Health care-associated infections: nosocomial infection – eg, surgical site, ventilator associated, catheter-related; handwashing procedures or inadequate number of handwashing stations; central line-associated blood stream infections; surgical site infections; catheter-associated urinary tract infections; ventilator-associated pneumonia
Documentation errors: electronic medical record (including voice-recognition software errors); record keeping; incorrect documentation (eg, wrong patient, wrong date, copying and pasting, pre-labeling)
Patient identification errors Mislabeling: transfusion errors related to mislabeling Verification/two identifiers: lack of dual validation, including verbal verification of lab results Diagnostic errors: errors in diagnostic studies; misinterpretation Monitoring errors Cardiac monitoring/telemetry Drug monitoring (warfarin, antibiotics) Device-related errors malfunction programming error incorrect use
Strategies to reduce error
Human factors engineering
Situational awareness
Hierarchy of effective interventions: forcing function; visual cues
Error analysis tools: error/near miss analysis; failure modes and effect analysis; morbidity and mortality review; root cause analysis
Safety behavior and culture at the individual level: hierarchy of health care, flattening hierarchy, speak up to power; afraid to report, fear; psychological safety; closed-loop communication
Teamwork: principles of highly effective teams; case management; physician teams, physician-physician communication; interprofessional/intraprofessional teams; strategies for communication among teams, including system-provider communication, physician-physician communication (eg, consultations), interprofessional communication, provider-patient communication