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Specifics about each Level and each Item:
What you do you need to know:
Level 2
• Identifies and reports errors
and near-misses
First,
each resident needs to know the definition of medical
error and near miss.
Error: An act of commission (doing something wrong)
or omission (failing to do the right thing) that leads
to an undesirable outcome or significant potential for
such an outcome. For instance, ordering a medication for
a patient with a documented allergy to that medication
would be an act of commission. Failing to prescribe a
proven medication with major benefits for an eligible
patient (e.g., low-dose unfractionated heparin as venous
thromboembolism prophylaxis for a patient after hip
replacement surgery) would represent an error of
omission.
Close call (near miss): An event, situation, or
error that took place but was captured before reaching
the patient. For example, penicillin was ordered for a
patient allergic to the drug; however, the pharmacist
was alerted to the allergy during computer order entry,
the prescriber was called, and the penicillin was not
dispensed or administered to the patient. Or the wrong
drug was dispensed by pharmacy, and a nurse caught the
error before it was administered to the patient.
Next,
each resident needs to know about the UH PASS Report
(Patient Advocacy & Shared Stories) which is on the UH
intranet at:
https://intranet.uhhospitals.org/ClinicalPatientSupportServices/QualityCenter/PASSReports.aspx
Residents
are expected to use the PASS system to report any
medical errors and near misses.
Level 3
• Describes potential sources of
system failure in clinical care such as minor, major,
and sentinel events
Resident
must know the definition of a sentinel event.
Sentinel Event: An adverse event in which death or
serious harm to a patient has occurred; usually used to
refer to events that are not at all expected or
acceptable—e.g., an operation on the wrong patient or
body part. The choice of the word sentinel reflects the
egregiousness of the injury (e.g., amputation of the
wrong leg) and the likelihood that investigation of such
events will reveal serious problems in current policies
or procedures.
Being
above to describe potential source of clinical system
failures will come from participation in the monthly
Neurology M&M conference and the PGY4 EQUIPS rotation,
the latter includes Neurology QA; Medicine QA; Review of
Pass reports; Mortality Reviews; and Mock regulatory
body audits (CLIPPS audits); and Risk management.
Level 4
• Participates in a team-based
approach to medical error analysis
Reaching
this milestone will be accomplished by presentation as a
PGY4 resident to the Neurology M&M Conference several
times through the senior year, and working with Dr.
Shapiro and other attendings on those presentations. In
addition, the milestone will be reached as a result of
the all the scheduled activities during the PGY4 EQUIPS
rotation. |
