Patient Safety Questions and Correct
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Anesthesia Patient safety Foundation APSF
Ans: first organization developed expressly to improve safety
for patients under Ellison Pierce, Jr. MD while president of Am
Soc of Anesthesiologist. He established a Committee on Pt
Safety and Risk Management then 2 yrs later proposed an
independent foundation which became APSF
Cofounders of Institute for Healthcare Improvement
Ans: Don Berwick MD and Paul Batalden MD and Gene Nelson
NEJM Harvard Medical Practice Study 1 and II
Ans: found evidence that a significant number of pts are
harmed by treatment: Adverse events occurred 3.7% of
hospitalizations and 27.6% were due to negligence. 2.6% were
permanently disabling and 13.6% led to death.
Dr. Lucian Leape
Ans: coauthor of Harvard Medical Practice Study who became
a prominent leader of the pt safety movement. He presented
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statistical evidence of the occurrence of harm in an essay titled
"error in Medicine" which appeared in JAMA 12/94
Error in Medicine categories of error
Ans: medication erroro, missed diagnoses, and operational
errors such as delayed treatment, the role of complexity and
culture in medicine, the model of safety improvement offered
by aviation, and the effect that medicine's culture of denia l has
on physicians involed in medical mistakes
Annenberg Conferences
Ans: Two notable conferences in the 1990s to advance pt
safety. The AMA debuted teh National Patient Safety
Foundation, formally established in 1997 as a catalyst for action
modeled on the APSF.
Institute of Medicine (IOM) charged the Committee on Quality of Care
in America with developing a strategy that will result in a threshhold
improvement in quality over the next ten years
Ans: 1998
To Err is Human
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