Medical Error Management Online 6-CME Training

Medical Error Management

Hundreds of thousands of patients are harmed or die each year due to unsafe practices in healthcare organizations. Unexpectedly, such unsafe healthcare practices have shifted medical error to be the third leading cause of death in the USA (251,454 patients die in hospitals each year) as per a published literature review in the BMJ in May 2016. Globally it is believed that medical errors kill more people than HIV, Malaria, and Tuberculosis, combined as stated by the Patient Safety Movement Foundation, USA.

This Medical Error Management Workshop is tailored to build a strategy that identifies, prevents, and mitigates medical errors and works with consequences. Participants will learn how to cultivate a patient safety culture in the healthcare organization, works toward excellence, and finally, know the current legislation in Bahrain on medical error including the NHRA Policy for Reporting Sentinel Event and the Supreme Council of Health Decision Number 95 for the year 2019 regarding investigation and notification of Medical Errors and Sentinel events.

OBJECTIVES AND TOPICS TO BE COVERED:

Attendees of the Medical Errors Management Workshop will learn how to:

1. Know the epidemiology of medical error and the research behind it

2. Identify definitions, types, causes, and common venues of medical errors

3. Learn how to create Non-Punitive Culture to enhance reporting of Medical Error

4. Learn how to develop a policy on Reporting Medical Error

5. Learn the framework of the Incident Reporting Form

6. Learn how to use data to identify TRENDING medical errors and how to address them

7. Use Root Cause Analysis Tools to identify root causes of medical error

8. Learn strategies to prevent, mitigate and treat medical error by applying the 18 Patient Safety Targets of the Agency for Healthcare Research and Quality (AHRQ)

9. Identify the common types of Medication Errors and how to prevent them

10. Identify the different types of Surgical Errors and learn how to prevent them

11. Identify different types of Communication Errors and learn how to prevent them

12. Learn how to manage the First Victim, patient, and family, and the principles of disclosure technique. Learn principles of Second Victim management

13. Learn how to manage the medical error once it occurs

WHO SHOULD ATTEND?

This activity is designated for ALL HEALTHCARE PROFESSIONALS and Medical and Nursing Students.

By attending this workshop both organization and the participant will gain the following values:

Gaining Value for Organization

§ Avoid preventable claim

§ Positive Reputation

§ Client Trust

§ Client satisfaction

§ Improve business safety practices

Gaining Value for participants

§ Avoid Preventable Errors

§ Be a Risk Management, Safety and/or quality champion

§ Do no harm

§ Practice with self-confidence

1st Presentation: Epidemiology of Medical Errors:

1. Medical Errors as illustrated by Florence Nightingale

2. End Result System by Dr. Ernest Amory Codman

3. American Studies and Literature Reviews on Medical Error

4. To Err is Human Building Safer Healthcare Report

5. Dr. Marten McCarry Literature Review on Medical Error

6. Medical Errors Epidemiology in European Countries by the WHO

7. An Organization with a Memory Report, NHS, UK

8. GCC Publications on Medical Errors

2nd Presentation: Definitions, causes, and common venues of medical errors

1. Different definitions of Medical Errors as per WHO, Institute of Medicine and others

2. Classification of Medical Error: Commission/Omission, Near Miss, Adverse Event and Sentinel Event, WHO Harmful and Non-Harmful events

3. Different types of Medical Error example: Diagnostic, Treatment, Preventive, Communication, Equipment and Systematic Errors

4. Common Causes of Medical Errors: Faulty System, Faulty Process and Faulty Condition

5. Common Venues of Medical Errors in a hospital and medium and small setting healthcare.

3rd Presentation: Medical Error Management Policy

1. How to address Medical Error in the Policy Statement

2. Purpose of Policy

3. Process of Medical Errors Management and how to prevent, mitigate and manage

4. How to report medical error

5. Addressing Disclosure process

6. Finding Root Cause and prevent recurrence

7. Identifying trending medical errors

8. Creating Reporting System and Form

9. Managing second victim in a non-punitive way ( Ensuring Non-Punitive Culture).

4th Presentation: Management of Medications error

1. Medication rights

2. Types of Medical Errors

3. Addressing and measure to Prevent Look-alike and Sound-Alike LASA Medication errors

4. High Alert Medication errors, Highly Concentrated Electrolytes errors

5. Infusion Pump Errors and preventive measures

6. WHO Five Moments of Medication Safety

5th Presentation: Healthcare Communication Errors

1. Identify Patient Correctly

2. Safe Surgery Practice

3. Dangerous Abbreviation

4. Medication Reconciliation

5. Handoff communication Gap, ISBAR and IPASS Communication

6th Presentation: Medical Error Case Presentation

1. Illustrate a scenario on wrong patient management using a dangerous abbreviation that ended up by major medication error.

2. Emphasis on the 10 steps to be followed for managing a medical error.

3. Explain how to report a medical error using the established reporting system.

4. Explain the approach of Disclosure Technique

5. Explain the role of quality and patient safety team members to find the root cause and corrective actions to prevent the recurrence.

6. Explain the role and responsibility of the management to carefully mange the second victim.