Incident reporting: A key to improving patient safety
Patient Safety Quality Monthly
February 14, 2008
Reducing medical errors has become a prime focus of healthcare organizations and external agencies (e.g., IHI, Leapfrog, NCQA) since the Institute of Medicine report To Err Is Human: Building a Safer Health System, which stated that "at least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented."
Healthcare consumers expect error-free performance from those who care for them. But, as we know, errors occur. Although most errors are unintended, devastating outcomes can result. Reducing the incidence of medical errors requires gathering key information, trending outcomes, identifying common causes and apparent causes, and designing quality initiatives to prevent future errors.
Learning from actual events - whether or not an untoward outcome occurs - and near-miss events provides valuable information for improving patient safety and reducing hospital, physician, and staff liability exposure.
It is important to note that only a fraction of incidents and near misses are reported, which reduces the access to available systems safety information. To encourage reporting, facilities should:
Put a leadership-driven focus on patient safety
Implement a simple, easy-to-use reporting system
Create a nonpunitive system
Use data analysis tools
Solicit staff and physician feedback on trends, related quality initiatives, and improvement results
Use process and outcome analysis methods (root cause analysis, failure modes and effects analysis)
Future issues will focus on utilizing the techniques listed above to improve both the rate and quality of incident reporting and data analysis methods.
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Question of the Month | Expert Advice & Guidance
- Are there specific requirements for governing board members, as leadership, to receive education related to the 2009 TJC standards?
Yes. Specifically under the 2009 standard LD.01.07.01, governing board members are to be oriented to the hospital's:
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