Our healthcare systems are already built with successive layers of defenses to prevent hazards from reaching our patients, but occasionally despite our best efforts a hazard can sneak through all the defenses and cause harm. The holes in our defenses through which the hazard sneaks are errors. Errors do not occur randomly, there are usually…
ACGME Milestones The Rush Emergency Medicine Residency Patient Safety and Quality Improvement curriculum is based on the ACGME EM Milestones version 2.0, enacted in July 2021. As you’re aware, through your residency you’ll need to demonstrate proficiency in the various levels described in the milestones below. Both of these fall within the Competency Domain of…
Summary of the process What follows are steps for completing a root cause analysis. We’ll go into more detail for these in the text following the table. Much of this came out of the work of Sydney Dekker, who used it to evaluate airplane crashes. It applies well here to medicine as well. Event, hazard…
Quality Improvement is the business of making healthcare better. This is based on the same systems that drove Toyota to become a world leader in making cars. They concentrated on constantly making their processes better. Seems like the same should apply to healthcare. In fact, Paul Batalden said, “In healthcare everyone has two jobs: to…
Or Understanding “Human Error” Humans make mistakes. Any system that depends on perfect performance by humans is doomed to failure. In fact, the risk of an accident is more a function of the complexity of the system than it is the people involved. Humans are not the weak link in a process. We are a…