PS 101 Lesson 1: Understanding Adverse Events and Patient Safety
How can health care providers improve patient safety? The first step is to acknowledge that harm occurs, and the second step is to take action to prevent it. In this lesson, you’ll find out just how many people are affected by medical harm worldwide. You’ll go beyond the numbers to hear from people who have experienced harm from the health care system, and learn how it has changed their lives. Finally, you’ll explore the reasons that providing safe care isn’t always easy in an environment where powerful drugs, quick decisions, and persistent distractions are the norm.
Estimated Time of Completion: 35 minutes
Learning Objectives
After completing this lesson, you will be able to:
1. Summarize the scope of the problem of harm to patients within the health care system.
2. Describe the effect of health care-associated harm on patients and families.
3. Explain why blaming and punishing individuals for errors rarely improves patient safety.
Contributors
Author(s):
Doug Bonacum, MBA, CSP, Vice President for Safety Management, Kaiser Permanente View Profile
Robert Wachter, MD, Professor & Associate Chairman, Dept of Medicine, University of California San Francisco View Profile
Editor(s):
Laura Fink, Director, Editorial and Online Learning, Institute for Healthcare Improvement View Profile
Reviewer(s):
Barbara Edson, RN, MBA, MHA, VP, Clinical Quality, Health Research & Educational Trust (HRET) View Profile
Frank Federico, RPh, Vice President, Senior Patient Safety Expert, Institute for Healthcare Improvement View Profile
Lucian Leape, MD, Adjunct Professor of Health Policy, Harvard School of Public Health View Profile
Requirements
You must be a registered IHI.org user to take this lesson.
You must achieve a minimum score of 75% to successfully complete this lesson.