Adverse Events, Triggers, and Diagnostic Errors: Practical Aspects of Patient Safety and Risk Reduction for the Interdisciplinary Team

Session Year: 
Steven Levenson, MD, CMD Julie Britton, MSN, GCNS-BC, RN

This session will identify key components of an effective patient safety program in long-term and post-acute care, both generally and specifically for medical directors and the interdisciplinary team. It will discuss the use of trigger tools and cover numerous examples of triggers in three key areas: medications, care related issues, and infections. Discussion of actual cases will be used to illustrate how diagnostic errors are a major contributor to risk and adverse events. Many case examples will be used to explain the connections between concepts such as risk factors, precipitating factors, adverse events and adverse consequences, risk reduction, and mitigation of adverse consequences. Participants will have the opportunity to take actual clinical situations, identify related risks and precipitating events, and develop trigger tools and simple solutions that they can implement in their facilities. Actual cases and demonstration of the use of specific tools will help illustrate how patient safety can be built in to everyday practice and processes, including existing quality assurance and performance improvement activities.

3.5 Mangement