• Define ‘medical error’
  1. Recognize the various parties impacted by a medical error
  2. Define the types of medical errors related to diagnostics, treatment and prevention
  3. Describe the difference between an active error versus a latent error
  4. Outline the “swiss cheese” model for medical errors
  5. Explain the difference between quality and value

• Describe the history of PS/QI in medicine, highlighting the following 2 Institute of Medicine (IOM) landmark articles: 
  1. To err is human: building a safer health system (1999)
  2. Crossing the Quality Chasm: A New Health System for the 21st Century (2001)

References:

1. ¹Kohn LT, Corrigan JM, Donaldson MS (Eds). To err is human: building a safer health system.  A report of the Committee on Quality of Health Care in America, Institute of Medicine,  Washington, DC: National Academy Press, 2000.
2. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century.  Washington, DC: National Academy Press, 2001.

• Describe why measuring safety is important to the field of otolaryngology-head & neck surgery.

References:

1. Reason J, Carthy J, de Leval M.  Diagnosis “vulnerable system syndrome”: an essential prerequisite to effective risk management.  Qual Health Care. 2001; 10(suppl. 11): ii21-25.
2. Clancy CM.  Patient safety: one decade after To Err is Human. Patient Safety and Quality Healthcare (11 JUNE 2009).  
3. To err is human- to delay is deadly: ten years later, a million lives lost, billions of dollars wasted.  

• Recognize the benefits of otolaryngology clinical practice guidelines (CPGs).
  1. Define the rigorous process for CPG development
  2. List the limitations of CPGs  
  3. Identify examples of current CPG applications to otolaryngology practice

References:

1. Rosenfeld RM, Shiffman RN, Robertson P.  Clinical practice guideline manual, third edition: a quality driven approach for translating evidence into action.  Otolaryngol Head Neck Surg.  2013 Jan;148(1 Suppl):S1-55. 

• Explain the difference between traditional otolaryngology clinical research and otolaryngology PS/QI research
  1. Summarize when Institutional Review Board (IRB) approval is required for PS/QI research
  2. Define the Standards for Quality Improvement Reporting Excellence (SQUIRE) as it relates to the introduction, methods, results and discussion sections of a PS/QI research manuscript.
  3. Provide meaningful examples of otolaryngology PS/QI projects
  4. Define the Plan-Do-Check-Act steps in PS/QI projects

References:

1. Ogrinc G, Davies L, Goodman D, Batalden P, Davidoff F, Stevens D. SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process. BMJ Qual Saf. 2016 Dec;25(12):986-992.