Patient safety. Part II. Opportunities for improvement in patient safety

Abstract

The quality movement in medicine has prompted a shift from a "name, shame, blame" approach to medical errors to one in which each error is regarded as an opportunity to prevent future patient harm. This new culture of patient safety requires the involvement of all members of the health care team and learned skill sets related to quality improvement. A root cause analysis identifies the sources of medical errors, allowing system changes that reduce the risk. In large organizations, sentinel events and signals prompt chart reviews and reduce the reliance on voluntary reporting. Failure mode analysis prompts the development of safety nets in the case of a system failure. The second part of this two-part series on patient safety examines how the culture of patient safety is taught, how medical errors and threats to patient safety can be identified, and how engineering tools can be used to improve patient care. It also examines efforts to measure clinical effectiveness and outcomes in the practice of medicine. Learning objectives: After completing this learning activity, participants should be able to improve patient safety through an understanding of both the beneficial and adverse consequences of quality reporting, apply safety engineering tools to the practice of dermatology, and be able to establish a quality improvement plan for a dermatologic practice. © 2009 American Academy of Dermatology, Inc.