PPT-Prevention of Medical Errors

2017 Course purpose To provide an overview of medical errors in todays health care system and to identify the incidence and causes of medical errors and the risk factors disposing to medical errors and to provide strategies to prevent medical errors in the healthcare setting including by patients. Peter J. Fabri MD, PhD, FACS. Professor of Surgery; Professor of Industrial Engineering. University of South Florida. Why?. American healthcare is broken. . The most sophisticated healthcare in the world is unsafe, expensive, inefficient, wasteful, error-prone, and uneven. HSPM 712. Localio. , A.R., et al, "Relation Between Malpractice Claims and Adverse Events Due to Negligence," . N . Engl. J Med. , July 25, 1991, . 325. (4), pp. 245-251.. This article is part III of a series of articles from this study. Part I, with Brennan as the lead author, showed the incidence of malpractice. This article looks at how many malpractice claims were pursued. The Brennan article on a later slide is a follow-up five years later, looking at how the lawsuits came out. under 2% of medical negligence leads to malpractice claims . Health economics. Localio. , A.R., et al, "Relation Between Malpractice Claims and Adverse Events Due to Negligence," . N . Engl. J Med. , July 25, 1991, . 325. (4), pp. 245-251.. Studied . 31,429 patients discharged from 51 New York hospitals in 1984. . to Enhance Performance . and Patient Safety. . 2. . Ice Breaker. . 3. . Sue Sheridan Video. . 4. . Video Discussion. How are . residents . harmed as a result of. medical errors?. How can we prevent medical errors?. Mistake Proofing . (Poke Yoke). Presented . By The University of Texas-School of Public . Health. By the end of this module participants should be able to. :. Identify the concept and importance of mistake proofing (poke yoke). . Office of Advanced Practice. and. The Center for Patient & Professional Advocacy. . An patient with epilepsy presents . for . an elective procedure. Procedure was completed without incident. Anticonvulsant . Centers for Disease Control and Prevention. Burden of HIV in the United States. . . 1.2 M . ~. 50K. 1.2 million people . living with HIV. Approximately . 50,000 new infections annually. . Chapter Topics. Medical errors. Medication errors. Prescription filling process in community and hospital pharmacy practices. Medication error prevention. Medication error reporting systems. Learning Objectives. 11/29/2017. 1. Introduction. Medication errors responsible for numerous adverse outcomes, including death. This results in high cost (emotional and financial). General framework for handling dispensing errors. Developed through the APTR Initiative to Enhance Prevention and Population. Health Education in collaboration with the Brody School of Medicine at East Carolina University with funding from the Centers for Disease Control and Prevention. Robert L . Fogerty. , MD, MPH. Outline. Scope of the problem. Macro level. Micro level. Yale New Haven data. When errors occur. Disclosure and reporting. Root cause analysis. Swiss Cheese model. Corrective actions. Define the following terms:. communication. the process of exchanging information with others by sending and receiving messages.. verbal communication. communication involving the use of spoken or written words or sounds.. Philip A Routledge. James Coulson. All Wales Therapeutics and Toxicology Centre. Cardiff, Wales, UK. Case Study. A 44 year-old woman had a urinary tract infection and was prescribed the antibiotic nitrofurantoin for 10 days. Two weeks later she noticed numbness, pins and needles and tingling of the lower limbs up to mid-thigh. She was examined by a neurologist three months later, who stated that this was likely to have been a peripheral neuropathy related to the previous course of nitrofurantoin. She is referred to you (as a clinical pharmacologist) for advice.. Litigation and risk reduction strategies. Joel R. Garcia, MD FACC. Chief Quality Officer. Orlando Health Heart Institute . 2. Disclaimer. This lecture does not, in any way, constitute legal advice or the practice of law and is not intended to replace legal counsel..