Boot Camp Resources
Graphics
Data Inventory Example
Learn to Report & Report to Learn
Relationship between Patient Safety and Risk/Quality
Operationalizing Patient Safety Initiatives
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.
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
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)
Error Rates
Source: “Measuring Fall Program Outcomes” The Online Journal of Issues in Nursing – ANA
Gap Analysis & Other Tools
- Institute of Safe Medication Practice Self-Assessment Tool
- Institute of Healthcare Improvement (IHI) Appropriate Care Patient Safety Assessment Tool
- Department of Veterans Affairs Patient Safety Assessment Tool
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
- Comprehensive Unit Safety Program
- Patient Safety Leadership WalkRounds
- Hourly Roundings
- TeamSTEPPS®
- Partnership for Patients
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
