Medical Error Prevention: Patient Safety [copy]

Author: Garland E. Pendergraph, PhD, JD, MLS(ASCP)SM, HCLD/CC(ABB)
Reviewer: Alexandru Casapu, MBA, MLS(ASCP)CM, PBTCM

Medical Error Prevention is a comprehensive course that includes potential causes of medical errors in the clinical laboratory, important legislation and definitions, and steps laboratorians can take to reduce the impact of medical errors in their workplace. This course is an ideal part of an effective medical error reduction program and is appropriate for both experienced and novice laboratorians.

Objectives

  • List and describe the six aims of the Institute of Medicine (IOM) to improve health care quality.
  • Describe the IOM aims within the context of quality clinical laboratory services.
  • Define "total testing process" and recognize problems (errors) that could occur in each phase of the total testing process.
  • Identify outcomes of patient safety errors with respect to clinical laboratory services.
  • Discuss patient safety goals.

Course Outline

  • Six aims of the Institute of Medicine (IOM) to improve health care quality.
      • State of Healthcare Quality
      • Six Domains of Healthcare Quality as Defined by the National Academy of Medicine (NAM)
      • Improving Effectiveness
      • Patient-Centered Care and Timeliness
      • Preventing Medical Errors Through Patient Involvement
      • Efficiency and Equity
      • According to the National Academy of Medicine (NAM), quality healthcare systems in the United States should be __________________ ?
  • IOM aims within the context of quality clinical laboratory services.
      • Clinical Laboratory Services and Safety
      • How might patient harm result from each of these problems related to clinical laboratory services? Consider your answer and then click on the defined ...
      • Clinical Laboratory Services and Effectiveness
      • Clinical Laboratory Services and Patient-Centered Care
      • Clinical Laboratory Services and Timeliness
      • Clinical Laboratory Services and Efficiency
      • Clinical Laboratory Services and Equity
      • Which of the following best defines "effective clinical laboratory services?"
  • Recognizing problems (errors) that could occur in each phase of the total testing process
      • Medical Errors
      • Factors that Contribute to Medical Errors
      • Total Testing Process
      • Safe Preanalytic Component of Total Testing Process
      • Safe Analytic Component of Total Testing Process
      • Safe Postanalytic Component of Total Testing Process
      • Patient-Centered Preanalytic Component of Total Testing Process
      • Patient-Centered Analytic Component of Total Testing Process
      • Patient-Centered Postanalytic Component of Total Testing Process
      • Identify the phase of the total testing process in which each error occurs.
  • Outcomes of patient safety errors with respect to clinical laboratory services.
      • Outcomes of Laboratory Services
      • The Laboratory Quality Management System and Non-Conforming Events (NCEs)
      • Reportable Errors
      • Reporting of Errors
      • NCEs of External Origin
      • NCEs of Internal Origin
      • Root Cause Analysis (RCA)
      • Root Cause Analysis (RCA), continued
      • Management of Non-Conforming Events (NCEs)
      • RCA Example: Cause-and-Effect Diagram
      • Failure Mode and Effect Analysis (FMEA)
      • Five Whys
      • A patient event occurs that results in a "near miss" (an event that was averted but may have resulted in death or serious injury). The error was caugh...
  • Sources of data to identify errors and patient outcomes
      • Monitoring Laboratory Processes to Prevent Medical Errors
      • Data Sources to Identify Errors
      • All of these sources may be useful for identifying patient safety problems EXCEPT?
  • Patient Safety Goals
      • The Joint Commission National Patient Safety Goals 2019 for Clinical Laboratories
      • National Patient Safety Goal: Identify Patients Correctly
      • Which of the following is NOT an acceptable patient identifier to use prior to performing venipuncture procedures?
      • National Patient Safety Goal: Improve Staff Communication
      • National Patient Safety Goal: Prevent Infection Through Hand Hygiene
      • What is generally considered the single most important procedure for preventing the spread of nosocomial (hospital-acquired) infection?
  • References
      • References

Additional Information

Level of Instruction: Intermediate
Intended Audience: Medical laboratory professionals
Author Information: Garland E. Pendergraph, PhD, JD, MLS(ASCP)SM, HCLD/CC(ABB) received his MSPH from the University of Kentucky in Lexington, his PhD in medical parasitology/entomology and mycology from the University of North Carolina in Chapel Hill and his law degree with a concentration in health care law from Concord Law School, Purdue University. He also did a Fellowship in Tropical Medicine at Louisiana State University School of Medicine. He is the author of a textbook in phlebotomy, a number of scientific articles, plus internet training programs. He is the director of five laboratories.
Reviewer Information: Alexandru Casapu, MBA, MLS(ASCP)CM, PBTCM has over 20 years of experience as a medical laboratory scientist, section supervisor, and laboratory manager. He is the former Director of Clinical Laboratory Technology Program at Georgia Piedmont Technical College. He is currently a Program Director at MediaLab, Inc. Alexandru holds BS degrees in Biology and Medical Technology from Clark Atlanta University and a MBA from the University of Georgia.

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