Efforts to improve patient safety have thus far fallen into two different but, not mutually exclusive categories: 1) a "safety science approach," drawing on lessons from other high risk industries to develop systems for reporting and learning from safety problems, recognizing the degree to which human errors are often facilitated by latent system problems, attention to human factors design principles affecting everything from equipment use to shift schedules and clinical environments, as well as the importance of teamwork, communication strategies, and organizational culture. 2) "evidence-based medicine approach": as with much clinical research, this approach targets common problems (in this case, harms caused by medical care as opposed to diseases), looks for interventions to prevent such complications (e.g., prophylaxis for venous thromboembolism, bundles for preventing central-line associated infections, bar-coding to prevent medication administration errors), assesses the evidence supporting these interventions and the degree to which effective implementation strategies also exist.

Beginning with a brief history of patient safety in health care, including high-profile cases and seminal studies that launched the widespread interest in patient safety, the course will cover key concepts and examples from both of the approaches to studying and reducing patient safety problems. The course will use examples of commonly discussed patient safety practices to convey the state of the evidence supporting the practices as well as key underlying concepts. For instance, the discussion of order sets and computerized decision support will include a review of what is known about their current effectiveness, but also include human factors concepts related to optimal order set design. Similarly, the discussion of checklists will include not just the evidence supporting their benefit (e.g., in peri-operative settings) but also the importance of attending to teamwork and communication issues that support successful implementation.

Objectives: 1) To describe the impetus for improving safety in health care. 2) To describe fundamental issues in human error and systems thinking related to improving patient safety. 3) To describe lessons from other high reliability organizations, including the importance teamwork and culture. 4) To analyze an evidence based approach to common health care safety problems. 5) To describe key elements of organizations that support safer care. 6) To analyze quantitative and qualitative measurement strategies in patient safety. 7) To identify strategies to gather patient perspectives to expand their role in supporting effective outcomes of care. 8) To describe and choose strategies to identify, analyze, and address patient safety issues.

This course will utilize some of the principles learned in Quality Improvements Methods course to illustrate patient safety issues (e.g., Analysis of Statistical Process Control charts).