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Internal Medicine · USMLE Step 3

USMLE Step 3 Quality Improvement and Patient Safety

Quality improvement methodology and patient safety and systems-based practice concepts as tested on USMLE Step 3.

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What does the acronym PDSA stand for in quality improvement?
Plan, Do, Study, Act
In the PDSA cycle, what is the purpose of the 'Study' step?
Analyze the data collected during the Do step to see whether the change had the intended effect
What is a sentinel event?
An unexpected occurrence involving death or serious physical or psychological injury that is not related to the natural course of the patient's illness
What is a 'never event' in patient safety?
A serious, largely preventable adverse event that should never occur, such as wrong-site surgery
What is a near miss (close call)?
An error or hazard that did not reach the patient or did not result in harm
What is an active error?
An error committed at the point of contact between a person and a system, with an immediate visible effect
What is a latent error?
A hidden flaw in system design, organization, training, or policy that contributes to error but may remain dormant for a long time
What does the Swiss cheese model illustrate in patient safety?
That harm occurs when holes (weaknesses) in multiple layers of a system's defenses line up, allowing an error to pass through
What is the main purpose of a root cause analysis?
To identify underlying system-level causes of an adverse event rather than assigning blame to an individual
Is root cause analysis a reactive or proactive method?
Reactive, it is performed after an adverse event or near miss has already occurred
What is Failure Mode and Effects Analysis (FMEA)?
A proactive method used before an error occurs to identify steps in a process that are likely to fail and their potential effects
What is the defect rate goal targeted by Six Sigma methodology?
No more than 3.4 defects per million opportunities
What is the primary focus of Lean methodology in process improvement?
Eliminating waste and non-value-added steps in a process
What are the three components of the Donabedian model for evaluating quality of care?
Structure, process, and outcome
In the Donabedian model, what does 'structure' refer to?
The setting and resources in which care is delivered, such as staffing levels or equipment

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