The modern view of catastrophes is that a cluster of factors come together, often 12 for an airline crash. The chain of causation view of the lawyer is from Scholasticism and the 13th Century.
This article provides a good review of what should go into medical error correction. I can say what they cannot. The unit of the hospital should be closed until the remedy has been found and incorporated.
Safety on the syllabus: Patient safety becoming part of medical education
Training in quality improvement is also being added. But some physician leaders say it's happening too slowly.
By Kevin B. O'Reilly, amednews staff. Posted April 19, 2010.
Robert O. Bonow, MD, chief of cardiology at Northwestern Memorial Hospital in Chicago, is pursuing a master's degree in quality and safety so he can be a better teacher and "transmit this to the next generation." [Photo by Tori Soper / www.torisoper.com]
Robert O. Bonow, MD, graduated from medical school in 1973. Caitlin Schaninger will graduate in June. Despite training in different generations, they see similar gaps in quality and safety education.
Much has changed in medical education in the nearly four decades that separate their medical school experiences.
What has remained largely unchanged is the lack of education most medical school graduates receive in the science and skills of quality improvement and patient safety -- how to deliver the right care to the right patient at the right time, and how to prevent a patient from being harmed.
Dr. Bonow is chief of the cardiology division at Northwestern Memorial Hospital in Chicago. He directs the Center for Cardiovascular Quality and Outcomes at Northwestern University's Feinberg School of Medicine and has served on several guideline and measure development bodies. Yet even with all his experience and expertise, Dr. Bonow felt compelled to pursue a master's degree in health care quality and patient safety.
* Boosting quality instruction
* Learning how errors happen
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"There's a knowledge gap that I think I personally have," he said. "I've been involved with a lot of quality initiatives, but have never had necessarily formal training in this stuff. I've learned it by osmosis for a decade and a half."
Northwestern University's program, launched in 2006, was believed to be the first of its kind. At least four other universities now offer similar master's degree programs aimed at addressing this training gap and helping to educate the faculty who will teach medical students and residents skills such as how to analyze errors and how to measure quality performance. Many medical schools and teaching hospitals are working to integrate quality and safety into their training, but critics say the pace of change is too slow and too inconsistent.
"Unmet needs"
Schaninger is among medical students across the country looking outside the formal curriculum of medical school for quality and safety training. As a student at the University of Chicago Pritzker School of Medicine she helped found a campus chapter of the Institute for Health Improvement's Open School for Health Professions.
The Open School offers free online quality and safety training to medical, nursing and other health professions students, and boasts chapters on 204 campuses in 41 U.S. states and 26 other countries.
Learning how errors happen
Medical educators often use a case-based approach on patient safety. Here is a sample lesson plan in which trainees are asked to do a root cause analysis of a real-life, fatal medication overdose given an infant. The chain of errors began when the resident writing the order was distracted by a phone call. Students are asked to answer these questions:
What happened? What were the gaps in quality of care? Did near misses, errors without harm and/or adverse events occur in the case? Hint: Make a chronological listing or flow diagram of events.
Why did it happen? What are the contributing factors? What are the active and latent factors?
What would prevent it from happening again? What are prevention strategies?
Trainees are then asked to describe how the following systemic factors may have contributed to the error:
Equipment: Design, availability and maintenance.
Environment: Staffing levels and skills, workload and shift patterns, administrative and managerial support, physical plant.
Teamwork: Verbal and written communication, supervision and assistance.
Staff: Knowledge and skills/training, competence, physical and mental health.
Institutional context: Economic and regulatory situation, availability and use of protocols, availability and accuracy of tests.
Organization/management: Financial resources and constraints, organizational structure, policy standards and goals, safety culture and priorities.
Patient: Complexity and seriousness of condition, language and communication, personality and social factors. Each group then presents its top three contributing factors, top three prevention strategies and its explanation of how the root cause analysis could improve safety in practice.
Source: "Modified Root Cause Analysis (RCA): Improving Patient Safety/Quality of Care," University of Missouri-Columbia School of Medicine, 2004
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