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From the course by Johns Hopkins University

Patient Safety and Quality Improvement: Developing a Systems View (Patient Safety I)

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Johns Hopkins University

Patient Safety and Quality Improvement: Developing a Systems View (Patient Safety I)

228 ratings

Course 1 of 7 in the Specialization Patient Safety

In this course, you will be able develop a systems view for patient safety and quality improvement in healthcare. By then end of this course, you will be able to: 1) Describe a minimum of four key events in the history of patient safety and quality improvement, 2) define the key characteristics of high reliability organizations, and 3) explain the benefits of having strategies for both proactive and reactive systems thinking.

From the lesson

Definitions in Patient Safety and Quality Improvement: An Overview

In this module, you will be reviewing several key terms and tools that are used in patient safety and quality improvement. This will allow you to begin to develop the common language used among patient safety and quality improvement experts and practitioners. By the end of this module you will be able to: 1) differentiate between the terms harm, hazard, error and risk within a patient safety and quality improvement framework, 2) describe how quality and safety overlap and how they are different and 3) differentiate between root cause analysis and a failure mode and effects analysis.

Definitions and Intersection of Quality and Safety3:36

Sentinel Event1:52

Root Cause Analysis (RCA)5:27

Failure Mode and Effects Analysis (FMEA)7:54

Meet the Instructors

Melinda Sawyer
Director, Patient Safety
Armstrong Institute for Patient Safety

[MUSIC]

Now I'd like to talk about harm.

Harm is psychological or physical injury or damage.

And there is a number of different subtypes of harm that I'll address.

The first one I want to talk about is inevitable harm.

And you can have inevitable harm associated with a procedure, a therapy,

or an action.

And the only way to prevent this kind of harm is not to do, or

not to administer that therapy, or not to conduct that procedure.

Some examples of inevitable harm are an allergy that a patient develops from

a appropriate therapy where the patient has had no previous history of allergy.

That's inevitable.

Also, the physical harm associated with surgery is another type of

inevitable harm.

Certainly when we do surgery, it's with the intent of doing more good than harm.

But when you cut into somebody, you're causing some form of inevitable harm.

The next type I want to talk about, or the next principle I want to talk about,

is that an inevitable harm today may not be inevitable tomorrow.

So, as an example, maybe we can develop a practical,

affordable test that we can administer to a patient before we

administer the drug to prevent an adverse event from happening.

We actually do have a really good example of that type of test.

There's a drug called abacavir that's used to treat HIV.

It turns out that in about 3% of the patients,

they'll develope a potentially fatal allergic reaction to it abacavir.

But fortunately, there's a genetic test that can be administered to

identify those patients susceptible to this type of reaction, and

then avoid using this drug in that patient subset.

Here's another really good example, and

that is a central line associated blood stream infection, or CLABSI for short.

It turned out that in the past, people pretty much said, well,

patients are going to get, occasionally they're going to get a CLASBI, and

there's not much we can do about it.

Well, Dr. Pronovost and his colleagues, in the reference that I've got on your slide,

actually published a study that shows that with the appropriate work

flow adjustments, with the appropriate bundles and behaviors and

system design, we can eliminate CLABSI.

So what was thought to be inevitable in the past is now preventable.

And actually you're going to hear more about CLABSI

in the lesson on high-reliability organizations.

The next kind of harm I want to talk about is preventable harm,

harm that's caused by an error.

And if that harm is very severe, it would be called a sentinel event.

And I'll talk more about sentinel events in a later lesson.

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