Deepening Our Understanding of a Patient Safety Defect-Investigating and Learning from Patient Safety Defects
Module 1 Introduction
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Interview with the Patient and His Wife
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Interview with the Nurse
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Interview with the Attending Physician
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Interview with the Resident
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Transcript of the Meeting with the Senior Executive
Joint Commission - Sentinel Event Alert 55: Preventing Falls and Fall-Related Injuries in Health Care Facilities
ECRI Institute: Falls
Veterans' Affairs National Center for Patient Safety: Falls Toolkit
Introduction to the Learning from Defects Tool
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Problem-solving and Proposing Interventions-Problem-Solving and Proposing Interventions
Module 2 Introduction
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So, What Is Your Problem?
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Key Metric
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Building Your A3
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Scope
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Specifying Performance Measure and Common Data Sources for Measurement
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Agency for Healthcare Research and Quality: Preventing Falls in Hospitals
Project Implementation and Stakeholder Engagement-Project Implementation and Stakeholder Engagement
Module 3 Introduction
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TRIP + 2
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Translating Evidence Into Practice: A Model for Large Scale Knowledge Translation
An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU
Implementation
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Embedding and Expanding the Project-Embedding and Expanding the Project
Module 4 Introduction
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Change Management Introduction
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2 More Es: Endure & Embed
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High Reliability Healthcare: Getting There From Here
A Model for Sustainability
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Two More Es: Expand
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A3 Reports: Tool for Process Improvement
Conclusion-Untitled Lesson
Module 5 Introduction
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