On completion of these exercises, the participant should be able to:
WMPS2301 - Epidemiology of Error
• Define medical errors based on the Institute of Medicine’s definition of the term.
• Describe the different types of errors that can occur.
• Categorize the different classes of errors that can occur in the workplace.
• Define a connection error and how it relates to communication problems.
• Contrast different examples of communication problems.
• Analyze the consequence of communication problems and how they relate to Patient Safety.
• Define the concept of a pathway and how it relates to information flow.
• Contrast different examples of pathway errors.
• Analyze the consequences of pathway errors and how they relate to Patient Safety.
• Define Human Performance as well as its attributes.
• Explain Active and Latent Errors as they relate to Human Performance.
• Recognize the classification of Cognitive, Organizational and Physical Failures.
• Describe examples of Human Performance errors in Pathology.
• Describe how Biologic Variation affects Patient Safety.
• Explain how Patient Preference may affect Patient Safety.
• Define the Levels of Care.
• Describe how organizations affect the quality of care through information flow.
• Explain how staffing levels for an organization can affect patient safety.
• Define technical errors as they relate to patient safety.
• Analyze ways to measure technical errors.
• Discuss frequency of technical errors.
• Describe the common sources for pathology related technical errors.
• Analyze the impact of technical errors.
• Apply standard lab policy and procedures as well as variability’s in inter-laboratory policy and procedures.
• Demonstrate the specific elements of document control that are required by the CAP.
• Describe CAP suggested practices for record-keeping compliance with proficiency testing.
• Explain the Joint Commission policy regarding sentinel events.
• Define latent and active failures along with their respective categories.
• Demonstrate practices that can reduce latent and active failures in your laboratory.
WMPS2302 - Systems Thinking and Its Effect on Patient Safety
• Describe the issues that necessitated the development of systems thinking.
• Explain how quality of care may be impacted by systems of care.
• Describe the attributes of a systems-based model of healthcare.
• Describe the six domains of quality as defined by the Institute of Medicine (IOM) in the context of laboratory services.
• Describe the four levels of a healthcare system in the context of laboratory services.
• Explain how the IOM domains of quality and the healthcare levels are interdependent in a dynamic system.
• Define a High Reliability Organization.
• Describe the five attributes of High Reliability Organizations.
• Explain the relationship between systems thinking and teamwork.
• Judge opportunities for using technology for High Reliability Organizations.
WMPS2303- Human Factors
• Describe how Human Factors Engineering may be applied to improving Patient Safety in the laboratory.
• Describe the factors in a laboratory system that impact laboratory staff performance, patient safety, and laboratory services.
• Explain the relationship between performance and laboratory system design and factors.
• Describe, in general terms, the intervention strategies to improve the quality and safety of systems.
• Discuss laboratory examples of interventions utilizing each of the intervention strategies.
• Judge safety and quality interventions in the laboratory that address the impact of human factors on staff performance.
WMPS2304 – Safety-Enhancing Technology
• Analyze quality assurance processes in routine pathology practice.
• Analyze different informatics driven technologies that enhance workflow and improve patient safety.
• Judge data obtained from the labs that show the efficacy of the informatics innovations.
• Recognize unintended consequences of technology use as they relate to patient safety.
WMPS2305– Communication
• Restate Patient Safety Goals employed by accrediting organizations such as the Joint Commissions and College of American Pathologists for improved communication among caregivers.
• Review tools available that measure communication of critical results among laboratory staff and providers.
• Demonstrate effective communication skills through documentation of caregiver critical results encounters.
• Define collaboration as it relates to the health care setting.
• Practice collaborative strategies with the ultimate outcome of attaining a collegial work environment.
• Assess the challenges related to communication of information when patients are transitioned from one health care setting to another.
• Discuss problems related to pending laboratory tests during patient discharge.
• Describe best practices for reducing patient safety risks associated with transition of care.
• Apply the SBAR technique for communicating with other members of a health care team.
• Apply the ethical, legal, and policy-related basis for full disclosure.
• Define what constitutes a medical error.
• Analyze the Harvard Hospital’s process for full disclosure.
WMPS2306– Culture of Safety
• Describe the relationship between a positive patient safety culture and a laboratory’s ability to provide care.
• Assess your laboratory’s current stage of safety culture development using the appropriate model.
• Identify your laboratory’s specific dimensions of patient safety culture.
• Design changes aimed at culture improvement for specific dimensions of patient safety culture.
• Analyze the format and general content of patient safety culture questionnaires.
• Develop a patient safety culture questionnaire that is relevant to laboratory settings in order to obtain the most useful and valid information.
• Explain why efforts to improve patient safety culture are clinically important.
• Design a safety culture improvement intervention for the laboratory.
• Define “Leadership” and its influence on patient safety culture.
• Illustrate behaviors demonstrated by transformational leaders.
• Describe specific outcome measures that are impacted by the use of transformational leadership.
• Explain how differences in culture can affect Patient Safety accountability.
• Define barriers to physician accountability that affect compliance with patient safety practices.
• Recommend appropriate action for willful non-compliance with patient safety practices.
WMPS2307- Methods and Tools for Evaluating Safety Events
• Explain the necessity of Root Cause Analysis.
• Describe how to perform a Root Cause Analysis.
• Distinguish the advantages and disadvantages of using a Failure Modes and Effects Analysis (FMEA) to an ISO risk assessment.
• Explain the performance of an FMEA.
• Define a Risk Assessment and its components.
• Explain the performance of a risk assessment.
• Define the legal obligations of healthcare facilities related to medical device incident reporting.
• Discuss the importance of reporting products problems to the manufacturer.
• Explain the benefits of voluntary reporting systems.
WMPS2308 - Fundamentals of Quality Improvement
• Define Quality Improvement terms.
• Describe the process for Quality Improvement.
• Determine methods for measuring Quality Improvement.
• Review a case study of a Quality Improvement process.