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Public HealtH ScienceS ` PUBLIC HEALTH SCIENCES—HEALTHCARE dELIVERy Public HealtH ScienceS ` PUBLIC HEALTH SCIENCES—QUALITy ANd SAFETy SectiOn ii 273

` PUBLIC HEALTH SCIENCES—QUALITy ANd SAFETy

Safety culture Organizational environment in which everyone Event reporting systems collect data on errors for
can freely bring up safety concerns without internal and external monitoring.
fear of censure. Facilitates error identification.

Human factors design Forcing functions (those that prevent Deficient designs hinder workflow and lead to
undesirable actions [eg, connecting feeding staff workarounds that bypass safety features
syringe to IV tubing]) are the most effective. (eg, patient ID barcodes affixed to computers
Standardization improves process reliability (eg, due to unreadable wristbands).
clinical pathways, guidelines, checklists).
Simplification reduces wasteful activities (eg,
consolidating electronic medical records).

PDSA cycle Process improvement model to test changes in
real clinical setting. Impact on patients:
ƒ Plan—define problem and solution Do
ƒ Do—test new process lan P
ƒ Study—measure and analyze data
ƒ Act—integrate new process into workflow

Study

Act

Quality measurements
mEASURE EXAmPLE
Structural Physical equipment, resources, facilities Number of diabetes educators
Process Performance of system as planned Percentage of diabetic patients whose HbA 1c was
measured in the past 6 months
Outcome Impact on patients Average HbA 1c of patients with diabetes
Balancing Impact on other systems/outcomes Incidence of hypoglycemia among patients who
tried an intervention to lower HbA 1c

Swiss cheese model Focuses on systems and conditions rather than
an individual’s error. The risk of a threat Potential failures
in defense strategy
becoming a reality is mitigated by differing Hazard
layers and types of defenses. Patient harm can
occur despite multiple safeguards when “the
holes in the cheese line up.”

Harm
Defense
strategies

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