Anders- Avoiding Pitfalls in Patient Safety: Starting with Quality Assessment and Improvement!

Today we would like to welcome Dr. Megan Anders, Assistant Professor of Anesthesiology at the University of Maryland and QA/QI guru! In fact, her most recent quality improvement project involved analyzing the failures of tracheostomy management in the ICU and has led to a significant improvements at every level of care! Today she is gracious enough to take on such an arduous task of summarizing the diverse and complicated process of making global changes to the way we practice medicine.

Anders QA QI 2015 from on Vimeo.

Lecture Summary

(Pearls Provided by Dr. Faith Armstrong, UMMC Critical Care Medicine Fellow)


  • QA: Measures against a standard, looks at events on an individual level
  • QI: An active broad view of events that measure the same things as QA, but also actively look for solutions and look beyond the individual

We need to strive for a “Learning System”

  • Look for defects in every day operations
  • QI is part of a unit/team’s daily work, not just a one time “QI project”…we need to have continuous learning and not isolated projects


Quality Trilogy

  • Quality Planning: developing a new process
  • Quality Control: looking at whether that new process gives the intended outcome
  • Quality Improvement: what can we do to make it better

Juran Trilogy

Patient Safety Culture: Core values & behaviors of leaders/individuals that emphasize safety over other competing goals

  • Understand the culture you’re working in
  • A culture focused on patient safety can improve patient AND staff satisfaction

Quick Facts!

  • Select a change that is useful, NOT perfect
  • ADAPT from other institutions/floors/teams and don’t just copy
  • Avoid low-impact changes (posters, education symposiums)
  • Think about the size of the project…sometimes you must test small to ensure it’s a reasonable solution

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