John Hopkins University - Patient Safety and Quality Improvement: Developing a Systems View (Patient Safety I) 

The Scope of the Problem

History of Quality Improvement and Patient Safety: 1854 - 1966

History of Quality Improvement and Patient Safety: 1966 - Present

Mitigable or Preventable Harm: Crimean War, 1854-1856

"To Err is Human": Building a Safer Health System

"Crossing the Quality Chasm": A New Health System for the 21st Century

"Free From Harm": Accelerating Patient Safety Improvement Fifteen Years After "To Err is Human"

Institute of Medicine Report: To Err is Human

Institute of Medicine Report: Crossing the Quality Chasm: A New Health System for the 21st Century

National Patient Safety Foundation Report: Free From Harm: Accelerating Patient Safety Improvement Fifteen Years After To Err is Human

Error in Medicine

An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU

Lesson 1 Quiz

Definitions in Patient Safety and Quality Improvement: An Overview

Definitions and Intersection of Quality and Safety

Harm

Sentinel Event

Error

Hazard

Risk

Root Cause Analysis (RCA)

Failure Mode and Effects Analysis (FMEA)

Quality

Safety

Culture

Lesson 2 Quiz

High Reliability Organizing and Why it Matters

Overview of High Reliability

A Model for Understanding High Reliability

Analyzing Healthcare as a High Reliability Organization

High Reliability Organization Sociocultural Norms

Five Principles for High Reliability and Mindful Organizing

High Reliability Organization Behaviors and Habits

Patient Safety Tools of Mindful Organizing

Lesson 3 Quiz

Applying a Systems Lens to Healthcare

Definition of a System

Definition of Systems Thinking

Reductionistic Thinking vs. Holistic Thinking

Swiss Cheese Model

First Order and Second Order Problem Solving

Whose Problem Is It?

Oncology Infusion Clinic: Case Study

Proactive and Reactive Systems Thinking Strategies

Conclusions

Lesson 4 Quiz