Patient Safety, Error Reduction, and Risk Management
Core concepts
Understand error types: slips, lapses, mistakes, and violations. Know the Swiss cheese model and the difference between active failures and latent conditions. Learn the hierarchy of effectiveness for safety interventions: forcing functions > constraints > simplification > standardization > reminders > education. Understand root cause analysis (RCA) and failure mode and effects analysis (FMEA) - one retrospective, one prospective. Know the role of just culture and reporting systems. Recognize common health IT safety hazards: wrong-patient selection, copy-paste, alert fatigue, and default values.
Traps
Questions often rank education as a strong intervention when it is among the weakest. Another trap: confusing RCA (after an event) with FMEA (before an event). Also watch for blaming individuals when the question describes a system failure.
Rule of thumb
Prefer forcing functions and standardization over reminders and education. The strongest intervention makes the error impossible, not merely discouraged.
Worked example
Wrong-patient orders occur after a new EHR rollout. RCA reveals that patient banners are visually similar and the confirmation step is skippable. A forcing function (hard stop with patient identifier confirmation) is stronger than a reminder or a training module.