Boot Camp Resources

Graphics

data-inventory

Data Inventory Example

Report to Learn

Learn to Report & Report to Learn

Relationship between Patient Safety and Risk/Quality

Relationship between Patient Safety and Risk/Quality

operationalizing

Operationalizing Patient Safety Initiatives

Who's Accountable for Patient Safety

Who’s Accountable for Patient Safety

Resource Links

To Err is Human
Source: Institute of Medicine

Patient Safety & Quality Improvement Act of 2005
Source: Agency for Healthcare Research and Quality (AHRQ)

Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices
Source: Agency for Healthcare Research and Quality (AHRQ Evidence Report No. 43)

Error Reporting Systems & Common Formats
Source: PSO Privacy Protection Center (PSOPPC)

How Systems Thinking Can Add Non-Linear Intellignece To Digital Strategy – Schematic
Source: Centerline Digital (Steven Keith)

Executive Leadership & Risk Management Perception of External Patient Safety Drivers

Source: American International Group (AIG)

What Exactly is Patient Safety?
Source: Agency for Healthcare Research and Quality (AHRQ)

Who is accountable & responsible for Patient Safety?
Source: American Data Network Patient Safety Organization (ADNPSO)

What is the relationship of Patient Safety to Risk & Quality Management?
Source: American Data Network Patient Safety Organization (ADNPSO)

Different Roles, Same Goal: Risk and Quality management Partnering for Patient Safety
Source: American Society for Healthcare Risk management (ASHRM)

Synergy of Quality Risk & Patient Safety
Source: American Data Network Patient Safety Organization (ADNPSO)

How is Patient Safety achieved?
Source: National Patient Safety Foundation (NPSF)

The Science of Safety by Peter Provonost
Source: Dr. Peter Provonost, M.D., Director/Armstrong Institute for Patient Safety and Quality, Johns Hopkins presentation.

5 characteristics of High-Reliability Organizations
Source: National Patient Safety Foundation (NPSF)

System Thinking & Complexity
Source: (2006, 02). Complexity Theory as Applied to Nursing.

Error Definition
Source: Grober, Ethan D., Bohnen, John M.A., “Defining Medical Error”. Can J Surg. 2005 February; 48(1): 39-44

Types of Error Performance
Reason classified errors based on Rasmussen’s 3 levels of performance

Clinical Groupings of Errors
Source: Leape, Lucian; Lawthers, Ann G.; Brennan, Troyen A., et al. Preventing Medical Injury. Qual Rev Bull. 19(5):144–149, 1993. 

Ishikawa Diagram

Anatomy of an Error: Swiss Cheese Model

Human Error
Source: Grober, Ethan D., Bohnen, John M.A., “Defining Medical Error”. Can J Surg. 2005 February; 48(1): 39-44

Human Error: Basic Tenets

Mistake Proofing for Human Factors: Design Strategies

Communication
Source: TeamSTEPPS®

Accountability
Source: Hickson GB, Pichert JW, Webb LE, Gabbe SG. A complementary approach to promoting professionalism: Identifying, measuring and addressing unprofessional behaviors. Academic Medicine. 2007; Hickson GB, Moore IN, Pichert JW, Benegas Jr M. Balancing systems and individual accountability in a safety culture. In: Berman S, ed. From Front Office to Front Line. 2nd ed. Oakbrook Terrace, IL: Joint Commission Resources;2012:1-36.

Second Victims
Source: Scott SD, Hirschinger LE, Cox KR, McCoig M, Brandt J, Hall L. The natural history of recovery for the health care provider “second victim” after adverse patient events. Qual Saf Health Care. 2009;18:325-330 – quote

CMS and AHRQ Common Formats
Source: “AHRQ Common Formats – Information for Hospitals and State Survey Agencies (SAs) – Comprehensive Patient Safety Reporting Using AHRQ Common Formats”, Memo # 13-19-HOSPITALS Dated March 15, 2013

Common Formats
Source: Agency for Healthcare Research and Quality (AHRQ)

Data Inventory

Error Rates
Source: “Measuring Fall Program Outcomes” The Online Journal of Issues in Nursing – ANA

Gap Analysis & Other Tools

Process Flow Charting

Root Cause Analysis Video Library

Sentinel Events – SE
Source: The Joint Commission

Root Cause Analysis Process, Failure Mode Effect Analysis Process, & Proactive Risk Assessment

Framework for Implementation
Source: ADAPTS Implemenation Science Model; Journal of Healthcare Quality

Patient Safety National Initiatives

Patient Safety Competencies
Source: Beaudin, C.L. & Pelletier, L.R. (2012)  QSolutions: Essential Resources for the Healthcare Quality Professional, pg 3.  “The Safety Competencies” 1st Edition/August 2009; Enhancing Patient Safety Across the Health Professions; Canadian Patient Safety Institute.

National Patient Safety Foundation Patient Safety Certification

 

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