Table 1 .

Proposed Outline and Justification for a Patient Safety CME Curriculum
1.	Adverse drug events
	This module discusses the known mechanisms by which ADEs occur. Current and innovative methods for identifying sources of systematic errors need to be impressed on clinicians. The differences between error, adverse events, and harm must be taught. Formulas for best practice in medication prescribing (e.g., always check allergies, write legibly, check liver and renal functions when appropriate) need to be analyzed. Order entry for medications, bar coding of medications, and drug administration data collection are an important part of the curriculum.
2.	Errors of omission
	The method for showing clinicians how they can be certain not to forget what they are supposed to do in health care falls roughly into two categories. The first is knowing what is your personal responsibility (i.e., knowing your medicine and your job); the second is knowing how to organize your life so that you remember to do the things that you are supposed to accomplish. For the former, the curriculum should clearly lay out the responsibility of every member of the team in the patient care process. This must serve as a guide for individual members of the team to know their responsibilities and the responsibilities of their coworkers. The second objective provides guidance in documenting a clinician’s to-do list, effectively signing out patients to a coworker when appropriate, transmitting the needed patient information effectively whenever required, and related activities.
3.	Errors of commission
	How sure is sure? When do you know enough to take responsibility for a decision in medicine? How do you get back-up when you are unsure? How do you recognize that an error has been made? What is your responsibility with regard to correcting an error, if possible? What documentation is required to comply with patient incident and sentinel event reporting? Our curriculum must address these and other critical issues in this arena.
4.	Discharge planning
	The discharge planning process is discussed in detail. Documenting drugs and their proper use is always of utmost importance. This responsibility is extremely critical when patients are transferring to nursing homes because the discharge summary is used as orders for medications. Selecting a safe environment for a patient leaving the hospital can be challenging, and helpful procedures are discussed during this module.25 Discharge summaries vary in quality; therefore, essential features of a useful and usable discharge summary are identified.
5.	Transitions in level of care
	Going from the outpatient setting to the inpatient setting is often haphazard. Courses must be developed that teach the basic principles that should allow clinicians to make cogent judgments about the need for hospitalization. Similarly, transitioning to the outpatient setting in a safe and effective manner has certain associated principles that need to be employed to teach this module (e.g., safe mobility around the home for home-going patients to prevent falls in the elderly).
6.	Consultation
	Knowing when to consult a subspecialist for a particular medical condition is part of the art of medicine. However, some of the variation in practice is based on a clinician’s predispositions rather than the patient’s condition. Clinicians must gain a basic understanding of the well-accepted principles that the most seasoned clinicians use in making these decisions. Examples for this module may include determining which test would be best to order, resolving a poorly understood physical finding, and finding the most appropriate well-trained provider to perform a procedure that you are not qualified to perform yourself.
7.	Preoperative evaluation
	Medical complications, which occur after or during surgery, are one set of often preventable adverse events. Clinicians must be taught the basic principles involved in performing a rigorous preanesthesia medical evaluation.
8.	Safety of herb-drug interactions
	The safety of prescribing medications to patients who take various herbs is becoming of increasing relevance. The course should stress and outline for clinicians the important principles regarding the prescriptions of medications when patients are on therapies or diets that you, as a clinician, currently do not fully understand. This module must also include advanced search techniques to identify information at the point of care, which will empower clinicians to practice more safely when prescribing medications.