CSI:ME Case Studies In Medical Errors

Thursday, November 15, 2018, 12:00 AM - Monday, November 15, 2021, 12:00 AM PST, Online Course

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

This CME 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 a web-enabled, 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 healthcare providers to ensure safe patient care. 

Intended Audience

This course is designed to meet the educational needs of physicians and nurses and other interested allied health professionals in all specialties.

  Release Date: November 15, 2018
  Expiration Date: November 15, 2021
  Estimated Time to Complete: 1.25 Hours
  CME Credits Offered: 1.25
  Registration Fee: FREE

AMA PRA Category 1 Credits™ (1.25 hours), Non-Physician Participation Credit (1.25 hours)

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.
3. Evaluate root causes and contributing factors that lead to various medical errors.
4. Develop skills to apply in practice the appropriate procedures or steps to assure that such events are prevented in the future.

In support of improving patient care, Stanford Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. Credit Designation American Medical Association (AMA) Stanford Medicine designates this Enduring Material for a maximum of 1.25 AMA PRA Category 1 Credits TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

 

Cultural and Linguistic Competency

The planners and speakers of this CME activity have been encouraged to address cultural issues relevant to their topic area for the purpose of complying with California Assembly Bill 1195. Moreover, the Stanford University School of Medicine Multicultural Health Portal contains many useful cultural and linguistic competency tools including culture guides, language access information and pertinent state and federal laws.  You are encouraged to visit the Multicultural Health Portal: http://lane.stanford.edu/portals/cultural.html

Bibliography

Institute of Medicine “To Err is Human” report:  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 and Loeb J, “The Journey to High Reliability”  The Milbank Quarterly, Vol. 91, No. 3, 2013 (pp. 459–490)
https://www.jointcommission.org/assets/1/6/Chassin_and_Loeb_0913_final.pdf

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

Joint Commission Sentinel Event Policy and Procedure
https://www.jointcommission.org/sentinel_event_policy_and_procedures/

Joint Commission Hospital National Patient Safety Goals 2018
https://www.jointcommission.org/assets/1/6/2018_HAP_NPSG_goals_final.pdf

Heidi B. King, MS, CHE, James Battles, PhD, David P. Baker, PhD, Alexander Alonso, PhD, Eduardo Salas, PhD, John Webster, MD, MBA, Lauren Toomey, RN, BSBA, MIS, and Mary Salisbury, RN, MSN.  “TeamSTEPPS™: Team Strategies and Tools to Enhance Performance and Patient Safety”, Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 3: Performance and Tools).  Henriksen K, Battles JB, Keyes MA, et al., editors.

Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Aug.
https://www.ncbi.nlm.nih.gov/books/NBK43686/

Martin A Makary and Michael Daniel, “Medical error—the third leading cause of death in the US”’
BMJ 2016;353:i2139 (Published 03 May 2016)
https://www.bmj.com/content/353/bmj.i2139

More bibliographic information can be found in the Resources and References section.

Disclosures

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
Author

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.