2007-2008 Session Two: Resources

Listed here are the presentations from the January 28-31, 2008 Patient Safety Improvement Corps Conference in San Francisco.

1-  Human Factors Engineering and Patient Safety

This presentation builds upon the initial presentation on human factors engineering. There are three separate segments: Introduction, Heuristic Evaluation, and Usability Testing. All available as .ppt files.

2- High Reliability Health Care

This presentation provides an overview of reliability in health care, including definitions, measurement methods, and strategies to design for reliability. Available as a .ppt file.

3- Healthcare Failure Mode and Effect Analysis

By the conclusion of this presentation learners will understand the purpose of healthcare failure mode and effect analysis (HFMEA) and have a practical understanding of the steps of the HFMEA proactive risk assessment process. Available as a .ppt file

4- Safe by Design

In this presentation, John Reiling provided an overview of patient safety and how he utilized the patient safety design process principles in leading the architectural design and building of a new hospital facility in West Bend, Wisconsin. Available as a .ppt file.

5- Probabilistic Risk Assessment

David Marx delivered this presentation which looks at the history of probabilistic risk assessment, defines socio-technical probabilistic risk assessment (ST-PRA) and explains when, how, and why ST-PRA should be utilized to assess risk in the healthcare setting.   Available as a .ppt file.

6- Patient Safety and the “Just Culture”

PowerPoint file not available at this time.

7-  Financial Principles and Models for Analysis

The goals of this presentation are to provide familiarity with cost-benefit analysis, exposure to hands-on application of analysis, and plan to apply these tools to make the business case for patient safety. Available as a .ppt file. 

Additional documents used in the Business Case exercises:
1-Making the Business Case for Patient Safety
2-Business Case Equations Cognitive Aid
3-Business Case Exercise Directions
4-Patient Fall With Fractures
5-Patient Falls With Fractures Group Exercise
6-Patient Falls With Fractures Answer Key
7-Anticoagulation Adverse Drug Events Group Exercise
8-Missing Patients Group Exercise
9-Data Sets

8- Patient Safety Assessment Tool

The goal of this presentation by Lesley Taylor from NCPS is to introduce the Patient Safety Assessment Tool (PSAT), a cognitive aid developed to help patient safety managers identify physical plant vulnerabilities. Available as a .ppt file.        

9- AHRQ Patient Safety Products, Tools, and Resources.

Overview of products available from the Agency for Healthcare Research and Quality given by Marge Keyes. Available as a .ppt file.

10-System Level Implementation of the Culture of Safety Survey (HSOPS)

Jeff Norton from UK Healthcare shared his experience utilizing the Culture of Safety Survey. Available as a .ppt file.

11- AHRQ Patient Safety Indicators

The focus of this presentation is on the quality indicators developed by the Agency for Healthcare Research and Quality. Identification, development, and utilization of  the indicators and national trends in PSI rates are discussed.  Available as a .ppt file.

12-Patient Safety Network (PSNet) and AHRQ Web M&M by Robert Wachter

Available as a .ppt file.

13- Fundamentals of Evaluation

The purpose of this presentation is to clarify some commonly used terms and reasons for making decisions regarding clinical research, quality improvement, and program evaluation and to provide some guidance on structuring, evaluating, and reporting on a project.  Available as a .ppt file