Learning Objectives

1. Define the goal of critical incident monitoring.
2. Define a “near miss.”
3. Compare incident reporting systems with chart reviews and risk management in relation to preventable events.
4. Describe the purpose of a root cause analysis according to the JCAHO mandate of 1997.
5. Describe the template in the form of a tree or ”Ishikawa.”
6. List the limitations of root cause analysis.
7. Describe the functions of CDSSs.
8. State the incident rates of ADEs per 100 admissions.
9. Define a non- preventable ADE (adverse drug event).
10. Define corollary.
11. State the drug classification most commonly associated with preventable ADEs.
12. State which group of hospitalized patients benefit most from clinical pharmacists in reducing ADEs.
13. Describe a computerized ADE monitor.
14. List the economic consequences of injuries due to drugs.
15. List several “high risk” medications.
16. State the primary intention of a heparin nomogram.
17. List 2 reasons unit-dose dispensing of medications was developed.
18. Describe the shift of unit-dosing from the nursing ward to the pharmacy.
19. Describe the McLaughlin dispensing system.
20. State a common complaint by nurses about a Pyxis Medstation.
21. Define hand disinfection.
22. State what percent of hospitalized patients contract a nosocomial infection.
23. List one of the main reasons for poor handwashing compliance.
24. State the length of time in seconds that is recommended for adequate hand hygiene.
25. State the estimated cost per episode of each nosocomial infection.
26. List several statistics regarding cost and acquisition rate for hospitalized patients.
27. Describe the psychological effect of contact precaution on the isolated patient.
28. State the estimated cost associated with c. difficile in the hospitalized patient.
29. State the most common nosocomial infections.
30. State the percent of urinary tract infection that make up nosocomial infections.
31. Describe the use of silver in urethral catheters.
32. List the two antibiotics used for antimicrobial impregnated catheters.
33. Define catheter colonization.
34. List the three common organisms causing catheter-related infections.
35. List the maximum sterile barrier precautions.
36. State the most common skin prep agent used prior to insertion of a central venous catheter.
37. Define ventilator-associated pneumonia.
38. Define continuous oscillation and how it is tolerated by conscious patients.
39. State the goal of selective digestive tract decontamination.
40. List several potential pitfalls of localizing care to high-volume settings.
41. Describe the two general categories of complications from minimal access procedures.
42. State the percent of injuries predicted to occur during a surgeon’s first 30 cases.
43. Define a surgical site infection.
44. Define antimicrobial prophylaxis and its purpose.
45. List the consequences of intraoperative hypothermia.
46. List complications of central venous catheterization after placement.
47. State the greatest benefit of ultrasound guidance.
48. State the number of sponge, sharp, and instrument counts recommended and describe each.
49. State the surgery where most retained sponges are found.
50. Describe the “checkout list” as stated in 1987 by the FDA.
51. State why a generalized checklist would be difficult or impossible.
52. List examples of invasive monitors.
53. Define capnography.
54. State the most common medical complication of surgery.
55. List the benefits of beta-blockade for elderly patients.
56. List the strongest predictor of future falls.
57. List the problems of wearing an external hip protector.
58. List two tools that are widely used to identify at-risk patients.
59. State the measures required with the Omnibus Budget Reconciliation Act of 1987.
60. State the cost of treating a pressure ulcer.
61. Define delirium.
62. List general strategies to prevent delirium.
63. List the members of a consultation team provided by published studies and common features.
64. List the functions of a multidisciplinary team in a GEM unit.
65. Describe a GEM unit.
66. Define “clinically silent.”
67. State the “gold standard” for diagnosis of DVT.
68. List the reasons DVT prophylaxis is under used.
69. List the major risk factors for radiocontrast-induced nephropathy.
70. State the percent of hospitalized patients who are malnourished.
71. State a complication associated with TPN.
72. List the three risks of stress ulceration and GI bleeding.
73. Describe teleradiology.
74. Describe the high-risk patient.
75. State the most effective delivery method for inpatient settings.
76. State the function of acute pain services post-operatively.
77. List the most common side effects of patient-controlled analgesia with opioids.
78. Describe a closed ICU model.
79. State what part of a nurse’s job is the largest.
80. Describe how increasing the percentage of RNs in the skill mix has decreased risk-adjusted mortality.
81. Define the term High Reliability Organization.
82. Describe the safety climate.
83. Define ergonomics.
84. Describe the experiment of recognizing six alarms at one time.
85. Define sign-out.
86. State the two most common reasons reported by physicians for not notifying patients of abnormal results.
87. State the oldest and most common machine-readable ID system.
88. List several common factors in wrong-site surgery.
89. List the three primary components of effective crew management.
90. Describe the MedTeams behavior-based teamwork system.
91. List four advantages of simulation.
92. State two potential risks to simulation-based training.
93. Define “sleep debt.”
94. Describe how shift rotation impacts worker fatigue.
95. Define “sleep inertia.”
96. Describe intrahospital and interhospital transports.
97. State the mortality rate during interhospital and intrahospital transport.
98. Define informed consent.
99. State the grade level at which hospital forms are written, according to Hopper et al.
100. Define advance directive, living will, and durable power of attorney for health care.
101. State why advance directives often do not change end-of-life interventions.
102. Describe the five-page “Patient Fact Sheet.”
103. Define “practice guidelines.”
104. Define Critical Pathways.
105. Define a “clinical decision support system.”
106. List three techniques used to modify behavior of physicians.
107. List the purpose of survey results used by JCAHO.

Course Contents

PART I. Overview
1. An Introduction to the Compendium
1.1 General Overview
1.2 How to Use this Compendium
1.3 Acknowledgments
2. Drawing on Safety Practices from Outside Healthcare
3. Evidence-Based Review Methodology
PART II. Reporting and Responding to Patient Safety Problems
4. Incident Reporting
5. Root Cause Analysis
PART III. Patient Safety Practices & Targets
Section A. Adverse Drug Events (ADEs)
6. Computerized Physician Order Entry (CPOE) with Clinical Decision Support Systems (CDSSs)
7. The Clinical Pharmacist’s Role in Preventing Adverse Drug Events
8. Computer Adverse Drug Event (ADE) Detection and Alerts
9. Protocols for High-Risk Drugs: Reducing Adverse Drug Events Related to Anticoagulants
10. Unit-Dose Drug Distribution Systems
11. Automated Medication Dispensing Devices
Section B. Infection Control
12. Practices to Improve Handwashing Compliance
13. Impact of Barrier Precautions in Reducing the Transmission of Serious Nosocomial Infections
14. Impact of Changes in Antibiotic Use Practices on Nosocomial Infections and Antimicrobial Resistance—Clostridium Difficile and Vancomycin-resistant Enterococcus (VRE)
15. Prevention of Nosocomial Urinary Tract Infections
15.1 Use of Silver Alloy Urinary Catheters
15.2 Use of Suprapubic Catheters
16. Prevention of Intravascular Catheter-Associated Infections
16.1 Use of Maximum Barrier Precautions during Central Venous Catheter Insertion
16.2 Use of Central Venous Catheters Coated with Antibacterial or Antiseptic Agents
16.3 Use of Chlorhexidine Gluconate at the Central Venous Catheter Insertion Site
  16.4 Other Practices
17. Prevention of Ventilator-Associated Pneumonia (VAP)
  17.1 Patient Positioning: Semi-recumbent Positioning and Continuous Oscillation
  17.2 Continuous Aspiration of Subglottic Secretions
  17.3 Selective Digestive Tract Decontamination
  17.4 Sucralfate and Prevention of VAP
Section C. Surgery, Anesthesia, and Perioperative Medicine
18. Localizing Care to High-Volume Centers
19. Learning Curves for New Procedures—the Case of Laparoscopic Cholecystectomy
20. Prevention of Surgical Site Infections
  20.1 Prophylactic Antibiotics
  20.2 Perioperative Normothermia
  20.3 Supplemental Perioperative Oxygen
  20.4 Perioperative Glucose Control
21. Ultrasound Guidance of Central Vein Catheterization
22. The Retained Surgical Sponge
23. Pre-Anesthesia Checklists To Improve Patient Safety
24. The Impact Of Intraoperative Monitoring On Patient Safety
25. Beta-blockers and Reduction of Perioperative Cardiac Events
Section D. Safety Practices for Hospitalized or Institutionalized Elders
26. Prevention of Falls in Hospitalized and Institutionalized Older People
  26.1 Identification Bracelets for High-Risk Patients
  26.2 Interventions that Decrease the Use of Physical Restraints
  26.3 Bed Alarms
  26.4 Special Hospital Flooring Materials to Reduce Injuries from Patient Falls
  26.5 Hip Protectors to Prevent Hip Fracture
27. Prevention of Pressure Ulcers in Older Patients
28. Prevention of Delirium in Older Hospitalized Patients
29. Multidisciplinary Geriatric Consultation Services
30. Geriatric Evaluation and Management Units for Hospitalized Patients
Section E. General Clinical Topics
31. Prevention of Venous Thromboembolism
32. Prevention of Contrast-Induced Nephropathy
33. Nutritional Support
34. Prevention of Clinically Significant Gastrointestinal Bleeding in Intensive Care Unit Patients
35. Reducing Errors in the Interpretation of Plain Radiographs and Computed Tomography Scans
36. Pneumococcal Vaccination Prior to Hospital Discharge
37. Pain Management
  37.1 Use of Analgesics in the Acute Abdomen
  37.2 Acute Pain Services
  37.3 Prophylactic Antiemetics During Patient-controlled Analgesia Therapy
  37.4 Non-pharmacologic Interventions for Postoperative Plan
Section F. Organization, Structure, and Culture
38. “Closed” Intensive Care Units and Other Models of Care for Critically Ill Patients
39. Nurse Staffing, Models of Care Delivery, and Interventions
40. Promoting a Culture of Safety
Section G. Systems Issues and Human Factors
41. Human Factors and Medical Devices
  41.1 The Use of Human Factors in Reducing Device-related Medical Errors
  41.2 Refining the Performance of Medical Device Alarms
  41.3 Equipment Checklists in Anesthesia
42. Information Transfer
  42.1 Information Transfer Between Inpatient and Outpatient Pharmacies
  42.2 Sign-Out Systems for Cross-Coverage
  42.3 Discharge Summaries and Follow-up
  42.4 Notifying Patients of Abnormal Results
43. Prevention of Misidentifications
  43.1 Bar Coding
  43.2 Strategies to Avoid Wrong-Site Surgery
44. Crew Resource Management and its Applications in Medicine
45. Simulator-Based Training and Patient Safety
46. Fatigue, Sleepiness, and Medical Errors
47. Safety During Transportation of Critically Ill Patients
  47.1 Interhospital Transport
  47.2 Intrahospital Transport
Section H. Role of the Patient
48. Procedures For Obtaining Informed Consent
49. Advance Planning For End-of-Life Care
50. Other Practices Related to Patient Participation
PART IV. Promoting And Implementing Safety Practices
51. Practice Guidelines
52. Critical Pathways
53. Clinical Decision Support Systems
54. Educational Techniques Used in Changing Provider Behavior
55. Legislation, Accreditation, and Market-Driven and Other Approaches to Improving Patient Safety
PART V. Analyzing The Practices
56. Methodology for Summarizing the Evidence for the Practices
57. Practices Rated by Strength of Evidence
58. Practices Rated by Research Priority
59. Listing of All Practices, Categorical Ratings, and Comments


"The course was very detailed and inclusive of some things that I would not even think of in reference to patient safety before this course."

  1. Relationship of objectives to overall purpose/goal of the activity -  A
  2. Did the course meet its stated learning objectives? -  A
  3. Relevance of the content to the objectives -  A
  4. Effectiveness of the learning method -  A
  5. Did the course help you achieve your objectives? -  A
  6. Your assessment of course content -  A
  7. Were you satisfied with the overall handling of your order? -  A
  8. Did the course meet your expectations? -  A
  9. How long did it take you to complete the course? -  28 hours

                                                                                                     -  R.P., RN, LA

"Very informative and thorough." -  D.W., RN, NV.




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