$5-Assignment

Readings

· Course Text: Medical Quality Management: Theory and Practice

·

. Chapter 3, "Patient Safety" This chapter addresses common causes of errors and introduces tools that can help shed light on why specific errors have occurred. It also examines the characteristics of high-reliability organizations, which have a strong focus on safety.

· Course Text: Foundations in Patient Safety for Health Professionals

·

. Chapter 3, "Safety Improvement Is in Professional Practice" In this chapter, patient safety is examined as a professional practice issue. In addition, interdisciplinary collaboration is addressed as a key concept for the prevention of safety errors.

. Chapter 7, "Why Things Go Wrong" This chapter provides a brief introduction to the science of errors, including the distinction between systems errors and human factors errors.

. Chapter 9, "Safe Patient Care Systems" This chapter describes the characteristics and practices of systems that promote patient safety.

· Article: Wu, A. W., Lipzhutz, A. K. M., & Pronovost, P. J. (2008). Effectiveness and efficiency in root cause analysis. JAMA, 299(6), 685–687. Retrieved from the Walden Library databases. This article poses questions for consideration regarding the use of Root Cause Analysis (RCA) in health care.

· Article: Hitchings, K., Davies-Hathen, N., Capuano, T., Morgan, G., & Bendekovits, R. (2008). Peer case review sharpens event analysis. Journal of Nursing Care Quality, 23(4), 296–304. Retrieved from the Walden Library databases. This article examines the use of peer case review to identify and analyze issues related to nursing care of a specific patient. As you read the article, compare this approach to the descriptions of Root Cause Analysis presented in the other Learning Resources.

· Web Article: The Joint Commission. (2010). National patient safety goals. Retrieved from http://www.jointcommission.org/standards_information/npsgs.aspx Review the National Patient Safety Goals for the Application Assignment.

· Web Site: CDC's National Healthcare Safety Network (NHSN) http://www.cdc.gov/nhsn/ NHSN utilizes information technology to coordinate safety data from a variety of health care organizations. Read through the information presented on this Web site to become familiar with this system.

Optional Resources

· Book: Reason, J. (1990). Human error. New York, NY: Cambridge University Press.

· Book: The Joint Commission. (2009). Root Cause Analysis in Health Care: Tools and Techniques (4th ed.). Oakbrook Terrace, IL: Author.

· Brochure: American Hospital Association. (2003). The patient care partnership: Understanding expectations, rights, and responsibilities. Washington, DC: Author. Retrieved from  http://www.aha.org/content/00-10/pcp_english_030730.pdf

· Article: Pronovost, P. J., Rosenstein, B. J., Paine, L., Miller, M. R., et al. (2008). Paying the piper: Investing in infrastructure for patient safety. Joint Commission Journal on Quality and Patient Safety, 23 or 34(6), 342–348.

Readings

· Article: Gawande, A. A., et al. (2009, January). A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine, 360(5), 491–499. Retrieved from the Walden Library databases. This article discusses the implementation of checklists to reduce surgical complications at participating hospitals around the world through the World Health Organization's Safe Surgery Saves Lives program.

· Article: Laurance, J. (2009, August). Peter Pronovost: Champion of checklists in critical care. The Lancet, 374(9688), 443. Retrieved from the Walden Library databases. This article addresses Dr. Peter Pronovost's efforts to promote the use of checklists for patient safety.

· Article: Bosk, C. L., Dixon-Woods, M., Goeschel, C. A., and Pronovost, P. J. (2009, August). Reality check for checklists. The Lancet, 374(9688), 444–445. Retrieved from the Walden Library databases. This article examines how and why checklists may improve patient outcomes, noting aspects of the intervention that have often been overlooked.

· Article: Grol, R. (2001). Improving the quality of medical care: Building bridges among professional pride, payer profit, and patient satisfaction. Journal of the American Medical Association, 286(20), 2578–2 585. Retrieved from the Walden Library databases. In this article, the author discusses various approaches for improving quality.

· Web Article: World Health Organization. (2009). Safe surgery saves lives. Retrieved from  http://www.who.int/patientsafety/safesurgery/en/ The World Health Organization's Safe Surgery Saves Lives campaign is the subject of some of this week's articles. This campaign illustrates global efforts to improve health care quality.

Web Sites

· Web Resources: The Joint Commission. (2009). Speak Up Initiatives. Retrieved from  http://www.jointcommission.org/speakup.aspx There are a number of brochures related to patient safety at this Web site, including one on patients' rights. You may download and read those that are of interest to you.

Note: In addition to completing this week's required reading, you will also need to review the information on quality-related tools (e.g., Lean, Six Sigma) that was assigned in previous weeks of the course.

Optional Resources

· Web Site: Centre for Evidence Based Medicine http://www.cebm.net/ This center promotes the use of evidence-based medicine and provides support and resources to health care professionals to help maintain the standards of medicine.

· Article: Guyatt, G., Cairns J., Churchill D., et al. (1992). Evidence-based medicine: A new approach to teaching the practice of medicine. Journal of the American Medical Association, 268, 2420–2425.