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CSI: ME Case Studies In Medical Errors

Learning Objectives
1. Integrate NPSG requirements in clinical practice in the areas of patient identification, Universal Protocol, labeling and medication reconciliation
2. Develop practical skills to improve team communication and apply these skills when medical errors occur and to prevent medical errors in the future, i.e. immediate feedback, Team STEPPS
3. Evaluate root causes and contributing factors that lead to various medical errors
4. Develop skill to apply in practice the appropriate procedures or steps to assure that such events are prevented in the future
1.25 Credits CME

This engaging activity aims to improve the practicing physicians' and other health care providers' knowledge about the types of medical errors that can occur and different methods of mitigating and/or preventing these events from occurring by utilizing The Joint Commission guidelines and standards pertaining to the National Patient Safety Goals. The activity is an interactive program that permits the participant to work on medical events by investigating and analyzing root causes and/or contributing factors to comprehend how medical errors can occur. These are the skills that can be utilized on a daily basis by health care providers to ensure safe patient care.

Sponsored by the Stanford University School of Medicine. Presented by the Department of Quality and Clinical Effectiveness at Stanford Health Care.

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Activity Information

2020 Stanford University School of Medicine. All Rights Reserved

The content of this activity is protected by U.S. and International copyright laws. Reproduction and distribution of its content without written permission of its creator(s) is prohibited.

Credit Designation Statement: The Stanford University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The Stanford University School of Medicine designates this enduring material for a maximum of 1.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Commercial Support Acknowledgement: Stanford University School of Medicine has received and has used undesignated program funding from Pfizer, Inc. to facilitate the development of innovative CME activities designed to enhance physician competence and performance and to implement advanced technology. A portion of this funding supports this activity.

Disclosure Statement: The following planners and author have indicated that that they have no relationships with industry to disclose relative to the content of this activity:

Joseph Hopkins, MD, MMM

Clinical Professor, Medicine - Primary Care and Population Health Associate Chief Medical Officer

Stanford Health Care Course Director

Steven Chinn, DPM, MS, MBA

Administrative Director, Accreditation and Regulatory Affairs Interim Patient Safety Officer

Stanford Health Care

Clinical Associate Professor

Division of Primary Care and Population Health Department of Medicine

Stanford School of Medicine Co-Course Director


Institute of Medicine (US) Committee on Quality of Health Care in America, Kohn  LT, Corrigan  JM, Donaldson  MS, eds. To Err is Human: Building a Safer Health System. Washington (DC): National Academies Press (US); 2000. http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf
Chassin  M, Loeb  J.  The Journey to High Reliability.  The Millbank Quarterly. 2013; 91(3): 459–490. https://www.jointcommission.org/assets/1/6/Chassin_and_Loeb_0913_final.pdfGoogle Scholar
National Patient Safety Foundation.  RCA2: Improving Root Cause Analyses and Actions to Prevent Harm.  Boston, MA: National Patient Safety Foundation; 2015. http://www.ihi.org/resources/Pages/Tools/RCA2-Improving-Root-Cause-Analyses-and-Actions-to-Prevent-Harm.aspx
The Joint Commission.  Sentinel Event Policy and Procedures. https://www.jointcommission.org/sentinel_event_policy_and_procedures/
The Joint Commission.  Hospital National Patient Safety Goals 2018. https://www.jointcommission.org/assets/1/6/2018_HAP_NPSG_goals_final.pdf
King  HB, Battles  J, Baker  DP,  et al. TeamSTEPPS™: Team Strategies and Tools to Enhance Performance and Patient Safety. Henriksen  K, Battles  JB, Keyes   MA,  et al., editors.  Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 3: Performance and Tools). Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Aug. https://www.ncbi.nlm.nih.gov/books/NBK43686/
Makary  MA, Daniel  M.  Medical error—the third leading cause of death in the US.  BMJ2016;353:i2139 (Published 03 May 2016). https://www.bmj.com/content/353/bmj.i2139Google Scholar

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