Prevention of Medical Errors:
Patient Safety as a Foundation for Quality Care

Course Length: 2 hours  
Release date: July, 2008
Expiration date: December 31, 2010

Course is temporarily closed until further notice

 


Sponsored by

 

 

Course Description
 

This course will provide nurses, physicians and physical therapists and other health care providers with an overview of information on patient safety required by various licensing boards in Florida.  The focus of this course is systems failures as a cause for medical error rather than individual blame and systems improvements as a logical starting point for creating safer environments for patients and healthcare workers. Thus, the emphasis is on a team approach toidentify and improve the delivery system. 

 


Objectives
 

As a result of participating in this activity, participants should be able to describe:

    • Root cause analysis
    • Error reduction and prevention measures 
    • Patient safety processes

Additional Objectives for Nurses

  • Factors that impact the occurrence of medical errors
  • How to recognize error prone situations
  • Processes to improve outcomes
  • Responsibilities for reporting
  • Safety needs of special populations
  • Factors important for public education

Additional Objective for Physicians

  • Identify the five most misdiagnosed conditions as established by the licensing board

Additional Objectives for Physical Therapists

  • Education for physical therapists must also encompass:
    • Medical documentation and communication
    • Contraindications and indications of physical therapy and patient management
    • Pharmacological components of physical therapy and physical management

 

 

 

Target Audience
 

Nurses, physicians, physical therapists  seeking to fulfill their mandated requirement for continuing education in the prevention of medical errors and other health care workers interested in enhancing their knowledge of the prevention  of medical errors.       

 



Continuing Education Credit
 

Physicians: USF Health is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

USF Health designates this educational activity for a maximum of 2 AMA PRA Category 1 Credits™.  Physicians should only claim credit commensurate with the extent of their participation in the activity.

Nurses: The University of South Florida College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.  This activity is for 2 contact hours.

Physical Therapists:
The University of South Florida College of Medicine is an approved provider of Continuing Education for Physical Therapists pursuant to the Board of Physical Therapy chapter 64b17-9.  The University of South Florida College of Medicine designates this educational activity for up to 2.4  contact hours

 


Faculty
 

Course Director

Cynthia Mikos, PA, Lawyer, Private Practice

 

Course Reviewer

Pat Gorzka, PhD, ARNP, FAANP

 

Faculty

Cynthia Mikos, PA, Lawyer, Private Practice

 

 

 

Disclosure of Significant Relationships with Commercial Support
Companies/Organizations

The University of South Florida College of Medicine adheres to the ACCME Standards regarding commercial support of continuing medical education. It is the policy of the USF College of Medicine that the faculty and planning committee disclose real or apparent conflicts of interest relating to the topics of this educational activity, that relevant conflict(s) of interest are resolved, and that speakers will disclose any unlabeled/unapproved use of drug(s) or device(s) during their presentation. Detailed disclosure will be made in the course materials.
The University of South Florida College of Medicine (USF COM) endorses the standards of the ACCME that requires everyone in a position to control the content of a CME activity to disclose all financial relationships with commercial interests that are related to the content of the CME activity. CME activities must he balanced, independent of commercial bias and promote improvements or quality in healthcare. All recommendations involving clinical medicine must be based on evidence accepted within the medical profession.
A conflict of interest is created when individuals in a position to control the content of CME have a relevant financial relationship with a commercial interest which therefore may bias his/her opinion and teaching. This may include receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, stocks or other financial benefits.
— The USF COM will identify, review and resolve all conflicts of interest that speakers, authors or planners disclose prior to an educational activity being delivered to learners. Disclosure of a relationship is not intended to suggest or condone bias in any presentation but is made to provide participants with information that might be of potential importance to their evaluation of a presentation.
Relevant financial relationships exist between the following individuals and commercial interests


Speaker

Relationship

Company

Cynthia Mikos, PA, Lawyer, Private Practice

Nothing to Disclose

 

Patricia Gorzka, PhD, ARNP, FAANP

Nothing to Disclose

 

 

 

 

 

Course Instructions
 

Computer Requirements

  • Windows 98 or Higher (Millenium, 2000, XP)
  • Internet Access
  • Email Address

Course Instructions
This 2  hour online course consists of a videotaped presentation and associated Microsoft Powerpoint slides.
Registration is $35. Once payment is verified, you will recieve the link to the course material, and you must successfully complete the course within this 14 day period in order to obtain a certificate of completion.

Once you have participated in this course you will then be asked to complete the post test for your specialty and evaluation questions.
The first step is registration, which may be completed by the registration link at the bottom of this page. Once payment is verified, the participant will be given a link to the course material on the payment confirmation page. This link does not expire, so the course material can be viewed at any time via the link provided. Questions concerning registration may be made to USF Registration Staff during normal working hours using the contact information at the top of this page.

Video Presentation
This video presentation is in Windows Media Video (.wmv) format and lasts between 120 and 130 minutes. As the .wmv format was developed by Microsoft, CPD recommends the use of Internet Explorer and Windows Media Player to avoid proprietary incompatibilities or technical difficulties. Participants are encouraged to download and print the powerpoint presentation and use the printed powerpoint outline to record any notes during the presentation.

Post-Test
After viewing, the participant will be presented with a post-test for physicians, nurses and physical therapists and evaluation questions. If the participant scores under 80% on the post-test, the participant will be sent back to review again the course module(s) that contained the correct answer(s) and then have the opportunity to retake it. Once the participant passes the post-test, the participant will be presented with a course completion form which they must submit before receiving their CE certificate.

Course Completion and Evaluation
The Course Completion Form contains entry fields for personal information (Name, Address, etc.) to verify the information on your CE certificate, and a short Course Evaluation survey. Your CE certificate will be mailed to the address provided on the form within four to six weeks.

 

Registration
 

Once you register online, and your credit card is charged successfully, you will recieve a link to the course material on the confirmation page itself, then be able to view the course and take the post-test in one sitting if desired. You may also bookmark the page to come back to it later. Please be sure you have entered a valid e-mail address as the primary method for communication in this course is through e-mail.



The CPD Office at the University of South Florida College of Medicine reserves the right to cancel this activity due to unforeseen circumstances.

Accommodations for Disabilities: Please notify the CPD Office, 12901 Bruce B. Downs Blvd., MDC Box 60, Tampa, Florida, 33612 or call (813) 974-4296 a minimum of ten working days in advance of the event if a reasonable accommodation for a disability is needed. Events, activities and facilities of the University of South Florida are available without regard to race, color, sex, national origin, disability, age, or Vietnam veteran status as provided by law and in accordance with the University's respect for personal dignity.

 

 

Web References
 

 

Agency for Healthcare Research and Quality (2007). Advancing patient safety through state reporting systems [Electronic version]. Retrieved March 17t, 2007, from www.webmm.ahrq.gov/perspective.aspx?perspectiveID=43

Agency for Healthcare Research and Quality (2008). Physicians want to learn from medical mistakes but say current error-reporting systems are inadequate [Electronic version]. Retrieved March 17th, 2007, from http://www.ahrq.gov/news/press/pr2008/errepsyspr.htm

Agency for Healthcare Research and Quality (2007). Institute of Medicine, Washington, EC: Committee on optimizing graduate medical trainee (resident) hours and work schedules [Electronic version]. Retrieved March 17th, 2007, from http://www.ahrq.gov/news/press/sp120307.htm

American Academy of Pediatrics, AAP Policy (2003). Abstract: Prevention of medication errors in the pediatric inpatient setting committee on drugs and committee on hospital care; [Electronic version]. Retrieved March 17th, 2007, from www.aappolicy.aappublications.org/cgi/content/full/pediatrics;112/2/431

Florida Administrative Code. Requirements for prevention of medical errors education, F.A.C. 64B17-8.002.

Florida Administrative Code. License renewal and reactivation; continuing education, F.A.C. 64B8-13.005.

Florida Administrative Code. Continuing education on prevention of medical errors, F.A.C. 64B9-5.011.

Florida Administrative Code. Requirements for prevention of medical errors education, F.A.C. 64B17-8.002.

Florida Statutes. Internal risk management program, FS 395.0197.

Florida Statutes. Duty to notify patients, FS 395.1051.

Florida Statutes. Reports of adverse incidents in office practice settings, FS 458.351.

Florida Statutes. Internal risk management and quality assurance program, FS 400.147.

Committee on the Work Environment of Nurses and Patient Safety, Board on Health Care Services, Ann Page, Editor (2004). Keeping patients safe: Transforming the work environment of nurses. Institute of Medicine of the National Academies, Reference Book: Quality Chasm Series.

Institute of Medicine of the National Academies (2006). Preventing medication errors [Electronic version]. Retrieved March 17th, 2007, from http://www.iom.edu/CMS/3809/22526/35939/35943.aspx

R. Scott Evans, M.S., Ph.D (2008). IOM report on preventing medication errors [Electronic version]. Institute of Medicine of the National Academies. Retrieved March 17th, 2007, from:
LINK
LA TIMES

Susan Brink (2008). "It's never just one thing" that leads to serious error. Los Angeles Times.

National Patient Safety Foundation (2007). Emergency departments in crisis: Implications for accessibility, quality and safety. Current Awareness Literature Alert, Volume 11, Issue 2:1.

National Patient Safety Foundation (2007). Medication reconciliation: What every nurse needs to know. Current Awareness Literature Alert, Volume 11, Issue 2:1.

National Patient Safety Foundation (2007). Patient safety rounds: Description of an inexpensive but important strategy to improve the safety culture. Current Awareness Literature Alert, Volume 11, Issue 2:1.

National Patient Safety Foundation (2007). Prevention of pediatric medication errors by hospital pharmacists and the potential benefit of computerized physician order entry. Current Awareness Literature Alert, Volume 11, Issue 2:1.

Partnership for Clear Health Communication. Do you know? Which of the following is the strongest predictor of an individual's health status? [Electronic version]. AskMe3.org Educational Program Brochure. Retrieved March 17th, 2007, from www.askme3.org/pdfs/4973B_FH_ENG.pdf

Patient Safety & Quality Healthcare (2007). Clinical triggers and rapid response escalation criteria. Rapid Response Teams

Michael L. Millenson (2005). Still demanding medical excellence. Rutgers University Press, Policy Challenges in Modern Health Care, Chapter 10 [Electronic version]. Retrieved March 17th, 2007, from http://www.rwjf.org/pr/product.jsp?jsp?id=14976

Lucian L. Leape (2005). Preventing medical errors. Rutgers University Press, Policy Challenges in Modern Health Care, Chapter 11 [Electronic version]. Retrieved March 17th, 2007, from http://www.rwjf.org/pr/product.jsp?jsp?id=15002

Linda H. Aiken (2005). Improving quality through nursing. Rutgers University Press, Policy Challenges in Modern Health Care, Chapter 12 [Electronic version]. Retrieved March 17th, 2007, from http://www.rwjf.org/pr/product.jsp?jsp?id=14926

The Joint Commission (1998). Accreditation committee approves examples of voluntarily reportable sentinel events. Sentinel Alert, Issue 4 [Electronic version]. Retrieved March 17th, 2007, from www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_4.htm

The Joint Commission (2006). Using medication reconciliation to prevent errors. Sentinel Alert, Issue 35 [Electronic version]. Retrieved March 17th, 2007, from www.jointcommission.org/SentinelEvents/SentinelEventAlert/

The Joint Commission (2001). Look-alike, sound-alike drug names. Sentinel Alert, Issue 19 [Electronic version]. Retrieved March 17th, 2007, from www.jointcommission.org/SentinelEvents/SentinelEventAlert/

The Joint Commission (2008). 2008 National patient safety goals hospital program. National Patient Safety Goals [Electronic version]. Retrieved March 17th, 2007, from http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/08_hap_npsgs.htm

Lauran Neergaard (2008). Withholding payment for hospital errors catching on. Associate Press, The Tampa Tribune.

University of Rochester Department of Emergency Medicine (2007). Powerpoint presentation: The emergency pharmacist (Eph): A safety measure in emergency medicine; Part 1: Justification and Part II: Role of the Eph; Part III: Implementation [Electronic version]. Retrieved March 17th, 2007, from http://www.emergencypharmacist.org/doc/toolkit%20page/Pow erpoint%20tools/1-EPH%20JustificationREV.ppt  

 

 


Print References
 

Agency for Health Care Policy and Research. (1998). Research in action: Reducing errors in health care. AHCPR Pub. No. 98-P018, September 21, 1998.

Ammerman, M. (1998). The root cause analysis handbook. Portland, OR: Productivity.

Baptist Health Systems of South Florida (BHS). (2002). Promoting a culture of safety: A self-study module.

Beurhaus, P.I. (1999). Lucian Leape on the causes and prevention of errors and adverse events in health care. Image: Journal of Nursing Scholarship, 31(3), 281-286.

Bogner, M.S.(1994). (Ed.) Human error in medicine. Hillsdale, NJ: Lawrence Erlbaum Associates.

Cohen, M.R. (2000). (Ed.) Medication errors: Causes, prevention, risk management. Sudbury, MA: Jones and Bartlett Publishers.

Department of Veteran's Affairs (DVA). (1998). Patient safety: Listening to health care employees.

Eisenberg, D.M. et al. (1998). Trends in alternative medicine use in the United States, 1990-1997. Journal of the American Medical Association, 280 (18): 1569-1575.

Institute of Medicine (IOM) Committee on the Work Environment for Nurses and Patient Safety. Page, A. (ed.). (2004). Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academy Press.

Institute of Medicine (IOM) Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.

Institute of Medicine (IOM) Committee on Quality of Health Care in America, Kohn, L.T, Corrigan, J.M, & Donaldson, M.S. (eds.). (1999). To err is human: Building a better health system. Washington, DC: National Academy Press.

Joint Commission Resources (JCAHO). (2001). Front line of defense: The role of nurses in preventing sentinel events. Oakbrook Terrace, IL: Joint Commission Resources.

Korth, S. (2004). Using root cause analysis to analyze issues of safety. In Youngblood, J. & Hatlie, M.J. (Eds.). The Patient Safety Handbook. Boston, MA: Jones & Bartlett.

Leape, L. et al. (1995). Systems analysis of adverse drug events. Journal of the American Medical Association, 274(1): 35-43.

Moore, C. (2004). Health care literacy and patient safety: The new paradox. In Youngblood, J. & Hatlie, M.J. (Eds.). The Patient Safety Handbook. Boston, MA: Jones & Bartlett.

Reason, J. (1997). Managing the risks of organizational accidents. Brookfield, NY: Ashgate.

Reason, J. (1994). Foreword. In M.S. Bogner (Ed.) Human error in medicine. Hillsdale, NJ: Lawrence Erlbaum Associates.

Reason, J. (1990). Human error. New York, NY: Cambridge University Press.

Spath, P.L. (Ed.) (2000). Error reduction in health care. Chicago, IL: American Hospital Association Press.

Youngblood, J. & Hatlie, M.J. (2004). The Patient Safety Handbook. Boston, MA: Jones & Bartlett.

 


Privacy Policy
 

The University of South Florida Office of Continuing Professional Development (OCPD) has created a privacy policy to demonstrate our commitment to guarding the privacy of our clients. The following statements disclose our practices on gathering and disseminating information for this web site.

The OCPD has security measures in place to protect the loss, misuse, and alteration of the information under our control. The OCPD does not share or sell any individualís contact information, financial information, or unique identifiers to any commercial supporter, advertiser, or third party without the specific permission of the individual.

If you have any questions regarding the privacy policy, please contact the Office of Continuing Professional Development by phone at (813) 974-1200 or by E-Mail.