HCQM - Patient Safety: Questions With Correct
Solutions
First organization developed expressly to improve safety for patients.
Right Ans - Anesthesia Patient Safety Foundation - founded 1985.
Ellison Pierce Right Ans - Established the Committee on Patient Safety
and Risk Management in 1982; coined the term "patient safety", founded
the Anesthesia Patient Safety Foundation in 1985; delivered the Rovenstine
Lecture in 1996.
1996's Rovenstine Lecture (40 Years behind the Mask: Safety Revisited)
Right Ans - Ellison Pierce described the beginning of anesthesiology's
patient safety movement
1982 20/20's The Deep Sleep: 6000 will Die or Suffer Brain Damage
Right Ans - Inspired Pierce's Rovenstine Lecture about patient safety
After attending a workshop by Deming, Berwick realized he was misguided
because he had been Right Ans - An inspector rather than a promoter of
quality.
1988 Institute for Healthcare Improvement was founded by Right Ans -
Don Berwick, Paul Batalden, and Gene Nelson. The institute focuses on all
aspects of quality, but their discovery of a modern approach to quality
helped transform the patient safety movement.
Harvard Medical Practice Study I and II Right Ans - Published in 1991 by
the New England Journal of Medicine it had the results from two large
studies of adverse medical events and provided the evidence that
significant numbers of patients are harmed by medical treatment and a
framework for understanding the types of harm they experience.
Harvard Medical Practice Study I Right Ans - 30,000 Medical records
from 1984 non psych hospitals in NYS were screened for adverse events
(injury caused by medical management rather than underlying disease and
prolonged the hospitalization or produced a disability at the time of
, discharge) and negligence (care falling below the standard expected of
physicians in their community).
Harvard Medical Practice Study II Right Ans - Classified the injuries
described in Study I and the management errors that were responsible.
Results of Harvard Medical Study II Right Ans - Adverse events occurred
in 3.7% of hospitalizations and 27.6% of the events were due to negligence.
70.5% gave rise to disability lasting less than six months, 2.6% caused
permanently disabling injuries and 13.6% led to death. Unfortunately it did
not lead to immediate change.
Lucian Leape Right Ans - Co-author of the Harvard Medical Practice
Study; prominent leader in the patient safety movement; discovered how
cognitive psychology and human factors engineering were important
aspects of improving patient safety
1994's Error in Medicine published in the Journal of the American Medical
Association Right Ans - Written by Lucian Leape it presented statistical
evidence of the occurrence of harm caused by medical errors along with
lessons from other high risk industries such as aviation.
The first mainstream article in healthcare literature arguing for a systems
approach to safety. Right Ans - Error in Medicine by Lucian Leape.
In Error in Medicine, Leape identified 3 categories of medical errors
Right Ans - Medication errors, missed diagnoses, operational errors such as
delayed treatment.
In Error in Medicine, Leape states the most fundamental change that must
be made is Right Ans - Cultural. Errors must be accepted as evidence of
system flaws not character flaws.
Betsy Lehman 1994 Death Right Ans - Occurred due to a medication
error at Dana-Farber Cancer Institute. Published in the Boston Globe and
caused many to take Leape's Error in Medicine more seriously.
Solutions
First organization developed expressly to improve safety for patients.
Right Ans - Anesthesia Patient Safety Foundation - founded 1985.
Ellison Pierce Right Ans - Established the Committee on Patient Safety
and Risk Management in 1982; coined the term "patient safety", founded
the Anesthesia Patient Safety Foundation in 1985; delivered the Rovenstine
Lecture in 1996.
1996's Rovenstine Lecture (40 Years behind the Mask: Safety Revisited)
Right Ans - Ellison Pierce described the beginning of anesthesiology's
patient safety movement
1982 20/20's The Deep Sleep: 6000 will Die or Suffer Brain Damage
Right Ans - Inspired Pierce's Rovenstine Lecture about patient safety
After attending a workshop by Deming, Berwick realized he was misguided
because he had been Right Ans - An inspector rather than a promoter of
quality.
1988 Institute for Healthcare Improvement was founded by Right Ans -
Don Berwick, Paul Batalden, and Gene Nelson. The institute focuses on all
aspects of quality, but their discovery of a modern approach to quality
helped transform the patient safety movement.
Harvard Medical Practice Study I and II Right Ans - Published in 1991 by
the New England Journal of Medicine it had the results from two large
studies of adverse medical events and provided the evidence that
significant numbers of patients are harmed by medical treatment and a
framework for understanding the types of harm they experience.
Harvard Medical Practice Study I Right Ans - 30,000 Medical records
from 1984 non psych hospitals in NYS were screened for adverse events
(injury caused by medical management rather than underlying disease and
prolonged the hospitalization or produced a disability at the time of
, discharge) and negligence (care falling below the standard expected of
physicians in their community).
Harvard Medical Practice Study II Right Ans - Classified the injuries
described in Study I and the management errors that were responsible.
Results of Harvard Medical Study II Right Ans - Adverse events occurred
in 3.7% of hospitalizations and 27.6% of the events were due to negligence.
70.5% gave rise to disability lasting less than six months, 2.6% caused
permanently disabling injuries and 13.6% led to death. Unfortunately it did
not lead to immediate change.
Lucian Leape Right Ans - Co-author of the Harvard Medical Practice
Study; prominent leader in the patient safety movement; discovered how
cognitive psychology and human factors engineering were important
aspects of improving patient safety
1994's Error in Medicine published in the Journal of the American Medical
Association Right Ans - Written by Lucian Leape it presented statistical
evidence of the occurrence of harm caused by medical errors along with
lessons from other high risk industries such as aviation.
The first mainstream article in healthcare literature arguing for a systems
approach to safety. Right Ans - Error in Medicine by Lucian Leape.
In Error in Medicine, Leape identified 3 categories of medical errors
Right Ans - Medication errors, missed diagnoses, operational errors such as
delayed treatment.
In Error in Medicine, Leape states the most fundamental change that must
be made is Right Ans - Cultural. Errors must be accepted as evidence of
system flaws not character flaws.
Betsy Lehman 1994 Death Right Ans - Occurred due to a medication
error at Dana-Farber Cancer Institute. Published in the Boston Globe and
caused many to take Leape's Error in Medicine more seriously.
