Patient Safety, Quality Improvement, Ethics, and Professional Practice
Safety is a system property
Patient safety requires human factors, checklists, standardized handoffs, medication labeling, alarm management, and reporting systems. Understand error models (active versus latent failures), just culture, root cause analysis (RCA), and failure mode and effects analysis (FMEA). Quality improvement uses metrics, PDSA cycles, and audit feedback. Ethics includes informed consent, decision-making capacity, confidentiality, conflicts of interest, research ethics, and end-of-life care. Professionalism includes honesty after adverse events and appropriate disclosure.
Traps: blaming an individual often misses system causes. A signed consent form is not the same as informed consent. Capacity is decision-specific, not a global label. Emergency exception allows treatment without consent when imminent harm exists and no surrogate is available. Sentimentality is not a substitute for documenting a code status discussion.
Worked example: a medication swap causes a near miss. FMEA scores severity × occurrence × detection; a high score prompts barcode scanning, separation of look-alike vials, and a read-back. RCA asks why the system allowed the swap, not only who drew it up.
Rule of thumb: disclose harmful errors promptly and honestly, apologize, and focus on prevention.