HCQM-Patient Safety EXAM Questions & Answers
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First organization Anesthesia Patient Safety Foundation - founded 1985.
developed expressly to
improve safety for
patients.
Established the Committee on Patient Safety and Risk
Management in 1982; coined the term "patient safety",
Ellison Pierce
founded the Anesthesia Patient Safety Foundation in
1985; delivered the Rovenstine Lecture in 1996.
1996's Rovenstine Lecture Ellison Pierce described the beginning of
(40 Years behind the Mask: anesthesiology's patient safety movement
Safety Revisited)
1982 20/20's The Deep Inspired Pierce's Rovenstine Lecture about patient
Sleep: 6000 will Die or safety
Suffer Brain Damage
After attending a An inspector rather than a promoter of quality.
workshop by Deming,
Berwick realized he was
misguided because he
had been
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, 9/8/25, 7:33 AM HCQM-Patient Safety EXAM Questions & Answers | Latest Already Graded A+ UPDATE 2025|2026 Flashcards | Quizlet
Don Berwick, Paul Batalden, and Gene Nelson. The
1988 Institute for
institute focuses on all aspects of quality, but their
Healthcare Improvement
discovery of a modern approach to quality helped
was founded by
transform the patient safety movement.
Published in 1991 by the New England Journal of
Medicine it had the results from two large studies of
Harvard Medical Practice adverse medical events and provided the evidence
Study I and II that significant numbers of patients are harmed by
medical treatment and a framework for understanding
the types of harm they experience.
30,000 Medical records from 1984 non psych
hospitals in NYS were screened for adverse events
(injury caused by medical management rather than
Harvard Medical Practice
underlying disease and prolonged the hospitalization
Study I
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 Classified the injuries described in Study I and the
Study II management errors that were responsible.
Adverse events occurred in 3.7% of hospitalizations
and 27.6% of the events were due to negligence.
Results of Harvard 70.5% gave rise to disability lasting less than six
Medical Study II months, 2.6% caused permanently disabling injuries
and 13.6% led to death. Unfortunately it did not lead
to immediate change.
Co-author of the Harvard Medical Practice Study;
prominent leader in the patient safety movement;
Lucian Leape discovered how cognitive psychology and human
factors engineering were important aspects of
improving patient safety
1994's Error in Medicine Written by Lucian Leape it presented statistical
published in the Journal of evidence of the occurrence of harm caused by
the American Medical medical errors along with lessons from other high risk
Association industries such as aviation.
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