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SafetyQuest_Level-1

The Safety Quest: Level One course is designed for physicians to enhance patient safety through a series of online gaming modules that focus on identifying and mitigating risks in healthcare. Participants will learn to integrate best practices for patient safety, utilize quality improvement tools, and apply communication techniques to reduce adverse events. The course includes assessments to measure knowledge gain and emphasizes a team-based approach to prevent errors in patient care.

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Maheshwari Shakthi
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19 views

SafetyQuest_Level-1

The Safety Quest: Level One course is designed for physicians to enhance patient safety through a series of online gaming modules that focus on identifying and mitigating risks in healthcare. Participants will learn to integrate best practices for patient safety, utilize quality improvement tools, and apply communication techniques to reduce adverse events. The course includes assessments to measure knowledge gain and emphasizes a team-based approach to prevent errors in patient care.

Uploaded by

Maheshwari Shakthi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Safety Quest: Level One - QI Basics

About the course

. Intended Audience
This course is designed for physicians across all specialty areas.

Course Description
Modern healthcare is complex and has many opportunities for error. To
ensure patient safety, hospitals and healthcare systems must continually
strive to work together as a team, create a culture of patient safety, and
identify and mitigate risks. SafetyQuest is a sequential series of online
CME gaming modules (levels 1-4) that provide an innovative and
immersive experience to understanding the underlying causes of patient
safety issues. This unique educational program emphasizes a problem-
solving approach to preventing errors in all healthcare settings and seeks
to ensure that patients are provided with care that supports the key
quality aims of the Institute of Medicine. Throughout the series, learners
will work to save patients from preventable harm and will gain problem
solving quality improvement and safety tools to approach these issues.
Case-based scenarios using multiple game modalities will be used to put
these principles into practice and save future lives.

Learning Objectives

At the conclusion of this course, participants should be able to:

 Integrate best practice patient safety and goals of care (GOC)


communication techniques (e.g. IPASS handoffs, SBAR
communication, stop the line/CUS words/call for help early,
debriefing, GOC documentation) into practice with teams to reduce
the risk of adverse events and increase patient safety.

 Utilize principles from the Joint Commission’s National Patient Safety


Goals to reduce the risk of adverse events and increase patient
safety.

 Apply QI tools and concepts such as PDCA, A3, high reliability, and
the swiss cheese model to improve the quality of care for your
patients.

Assessment and Grading


The course begins with a Test Your Knowledge Pre-test that will determine
your baseline knowledge before beginning any modules. We ask that you
complete this short assessment to learn your strengths and weaknesses
with regard to the topics included in this course. You will only have one
attempt for each question. Pressing "submit" locks in your final answer. If
your answer is correct, you will have an opportunity to see an explanation
by pressing the "Show Answer" button. The score from the pre-test will
not count toward your final grade in the course. However, by comparing
your baseline score (pre-test) to your score on the final assessment (post-
test), you will be able to determine how much you learned.

At the end of the course, there is a final, comprehensive Post-test that will
determine your grade. You must receive a score of 75% or higher on the
post-test in order to receive a CME Certificate or Participation
Certificate. The first two questions are meant to assess your confidence
level after having completed the course. These two questions are not
graded and will not affect your post-test score. For the remaining
questions you will have two attempts per question (or one attempt for
questions with only two options) to pass the post-test. After you have
completed the post-test, please move to the next section to complete the
CME Evaluation and Claim Credit Instructions.

New Patient!

Name: Bernard Ali

Patient History:

Mr. Ali is a resident of a skilled nursing facility who was admitted last night
for a clostridium difficile infection complicated by delirium. His mental
status has quickly improved on metronidazole.

Patient Status:

You are called to the bedside where you are approached by the patient's
wife who asks why her husband was given oxycodone. She had previously
told you taking oxycodone has caused Mr. Ali to become excessively
sedated. You meant to order the oxycodone for another patient, but must
have ordered it in error for Mr. Ali as you were doing too many things at
once. What critical safety actions should you do at this time?

Chart

 Age: 75

 Gender: Male

 Medical/Surgical History: Moderate dementia, hypertension,


benign prostatic hypertrophy

 Social History: Classic car enthusiast

 Inpatient Medications: Ceftriaxone, Colace, Atenolol, Donepezil,


Tamsulosin

 Allergies: NKDA
 Code Status: DNR/DNI

 Catheters: None

Action Log - Medicine Reconciliation


While appropriate documentation of meds and allergies could have helped
earlier, it will do nothing to fix the present situation.

Code blue! Mr. Ali is intubated for acute respiratory failure.

-1000 points

 File Event Report

75: Yes! Congrats on using event reporting to alert hospital administration


this is a problem that is affecting patient safety on the front line.

 Call for Help Early

While a good idea in general, in this specific case reporting the error and
speaking with the family are key.

 Use Checklist

Using a checklist earlier may have prompted you to document allergies but at
this point in the patient scenario, it will not help you.

 Medicine Reconciliation

 While appropriate documentation of meds and allergies could have helped


earlier, it will do nothing to fix the present situation. Debrief

50: Good job – given how common multi-tasking and medication order entry
error are, taking time to debrief on this problem with your team is an
important part of developing ways to prevent this error with future patients.

 Use Order Set

Using an order set earlier may have prompted you to document allergies or
intolerances but at this point in the patient scenario, it will not help you.

CUS, SBAR, and I-PASS."

CUS – Concerned, uncomfortable, safety

SBAR – Situation, Background, Assessment, Recommendation

I-PASS - Illness severity, Patient summary, Action list, Situation awareness &
contingency planning, Synthesis by receiver
A3 is a structured problem solving and continuous improvement approach,
first employed at Toyota in the 1960's and typically used in lean methodology.
It provides a simple and strict approach systematically leading towards
problem solving in complex environments. Lean principles can be successfully
applied to the delivery of health care.

A3 leads towards problem solving over the structure, which tells a story on an
11.7 x 16.5 inch "A3" single sheet paper (which is the largest sheet of paper
that can fit into a fax machine). This is where the A3 process got its name.
The process is based on the principles of Deming's PDCA (Plan-Do-Check-Act).

PDCA

Plan – Recognize an opportunity and plan a change.

Do – Test the change. Carry out a small-scale study.

Check – Review the test, analyze the results and identify what you’ve learned.

Act – Take action based on what you learned in the study step.

A3 elements for each PDCA step –

Plan – Background, current state, future state/goal, root cause analysis

Do – Counter measures

Check – Effect confirmation

Act – Follow up actions.

Universal Protocol was created to prevent wrong person, wrong procedure,


wrong site surgery in hospitals and outpatient settings. Applies to all invasive
procedures that expose the patient to more than minimal risk.

The Universal protocol consists of three steps:

 A pre-operative/pre-procedure verification
 Marking the operative/procedure site
 A time out (final verification to be performed immediately before the
operation/procedure)

Mark the site when there is more than one possible location for a procedure and
when performing the procedure in a different location could harm the patient.

Before proceeding the entire team is in agreement on the following:

1. Correct patient
2. Correct procedure
3. Correct site
4. No Multi-tasking

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