Mandatory Error Reporting Systems
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DataSetsGEO ProfilesGSSGTRHomoloGeneMedGenMeSHNCBI Web SiteNLM CatalogNucleotideOMIMPMCPopSetProbeProteinProtein ClustersPubChem BioAssayPubChem CompoundPubChem SubstancePubMedPubMed HealthSNPSparcleSRAStructureTaxonomyToolKitToolKitAllToolKitBookToolKitBookghUniGeneSearch termSearch Browse Titles Limits Advanced Help NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.Institute of Medicine (US) Committee medical error reporting system on Quality of Health Care in America; Kohn LT, Corrigan JM, Donaldson MS,
Reporting Medical Errors To Improve Patient Safety
editors. To Err is Human: Building a Safer Health System. Washington (DC): National Academies Press (US); 2000. To
What Is A Systems Approach To Addressing Error?
Err is Human: Building a Safer Health System.Show detailsInstitute of Medicine (US) Committee on Quality of Health Care in America; Kohn LT, Corrigan JM, Donaldson MS, editors.Washington (DC): National Academies Press
Medication Error Reporting Procedure
(US); 2000.ContentsHardcopy Version at National Academies PressSearch term < PrevNext > 5Error Reporting SystemsAlthough the previous chapter talked about creating and disseminating new knowledge to prevent errors from ever happening, this chapter looks at what happens after an error occurs and how to learn from errors and prevent their recurrence. One way to learn from errors is to establish a reporting system. Reporting reporting medication errors in nursing systems have the potential to serve two important functions. They can hold providers accountable for performance or, alternatively, they can provide information that leads to improved safety. Conceptually, these purposes are not incompatible, but in reality, they can prove difficult to satisfy simultaneously.Reporting systems whose primary purpose is to hold providers accountable are "mandatory reporting systems." Reporting focuses on errors associated with serious injuries or death. Most mandatory reporting systems are operated by state regulatory programs that have the authority to investigate specific cases and issue penalties or fines for wrong-doing. These systems serve three purposes. First, they provide the public with a minimum level of protection by assuring that the most serious errors are reported and investigated and appropriate follow-up action is taken. Second, they provide an incentive to health care organizations to improve patient safety in order to avoid the potential penalties and public exposure. Third, they require all health care organizations to make some level of investment in patient safety, thus creating a more level playing field. While safety experts recognize that errors resulting in serious harm are the "tip of t
DataSetsGEO ProfilesGSSGTRHomoloGeneMedGenMeSHNCBI Web SiteNLM CatalogNucleotideOMIMPMCPopSetProbeProteinProtein ClustersPubChem BioAssayPubChem CompoundPubChem SubstancePubMedPubMed HealthSNPSparcleSRAStructureTaxonomyToolKitToolKitAllToolKitBookToolKitBookghUniGeneSearch termSearch Browse Titles Limits Advanced Help NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.Hughes error reporting system in healthcare RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville when an error occurs, which of the following is a productive response? (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Patient Safety and Quality: An Evidence-Based Handbook medication error reporting form for Nurses.Show detailsHughes RG, editor.Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr.ContentsSearch term < PrevNext > Chapter 35Error Reporting and DisclosureZane Robinson Wolf; Ronda G. Hughes.Author https://www.ncbi.nlm.nih.gov/books/NBK225170/ InformationZane Robinson Wolf;1 Ronda G. Hughes.21 Zane Robinson Wolf, Ph.D., R.N., F.A.A.N., dean and professor, La Salle University School of Nursing and Health Sciences. E-mail: ude.ellasal@flow2 Ronda G. Hughes, Ph.D., M.H.S., R.N., senior health scientist administrator, Agency for Healthcare Research and Quality. E-mail: vog.shh.qrha@sehguH.adnoRBackgroundThis chapter examines reporting of health care errors (e.g., verbal, written, or other form of communication https://www.ncbi.nlm.nih.gov/books/NBK2652/ and/or recording of near miss and patient safety events that generally involves some form of reporting system) and these events’ disclosure (e.g., communication of errors to patients and their families), including the ethical aspects of error-reporting mechanisms. The potential benefits of intrainstitutional and Web-based databases might assist nurses and other providers to prevent similar hazards and improve patient safety. Clinicians’ fears of lawsuits and their self-perceptions of incompetence could be dispelled by organizational cultures emphasizing safety rather than blame. This chapter focuses on the assertion that reporting errors that result in patient harm as well as seemingly trivial errors and near misses has the potential to strengthen processes of care and improve the quality of care afforded patients.Reporting ErrorsReporting errors is fundamental to error prevention. The focus on medical errors that followed the release of the Institute of Medicine’s (IOM) report To Err Is Human: Building a Safer Health System1 centered on the suggestion that preventable adverse events in hospital were a leading cause of death in the United States. This report em
Me Forgot Password? Login or Sign up for a Free Account My Topics of Interest My CME My Profile Sign Out Home Topics Issues WebM&M Cases Perspectives Primers Submit https://psnet.ahrq.gov/primers/primer/13/voluntary-patient-safety-event-reporting-incident-reporting Case CME / CEU Training Catalog Info Glossary About PSNet Help & FAQ Contact PSNet Email Updates Editorial Team Technical Expert/Advisory Panel Terms & Conditions / Copyright PSNet Privacy Policy External Link Disclaimer Patient Safety Primer Last Updated: August 2014 Voluntary Patient Safety Event Reporting (Incident Reporting) Topics Resource Type Patient Safety Primers Approach to Improving Safety Error Reporting error reporting Institutional Reporting More Share Facebook Twitter Linkedin Email Print Background Patient safety event reporting systems are ubiquitous in hospitals and are a mainstay of efforts to detect patient safety events and quality problems. Incident reporting is frequently used as a general term for all voluntary patient safety event reporting systems, which rely on those involved in events to error reporting system provide detailed information. Initial reports often come from the frontline personnel directly involved in an event or the actions leading up to it (e.g., the nurse, pharmacist, or physician caring for a patient when a medication error occurred), rather than management or patient safety professionals. Voluntary event reporting is therefore a passive form of surveillance for near misses or unsafe conditions, in contrast to more active methods of surveillance such as direct observation of providers or chart review using trigger tools. The Patient Safety Primer Detection of Safety Hazards provides a detailed discussion of other methods of identifying errors and latent safety problems. Characteristics of Incident Reporting Systems An effective event reporting system should have four key attributes: Box. Key Components of an Effective Event Reporting System Institution must have a supportive environment for event reporting that protects the privacy of staff who report occurrences. Reports should be received from a broad range of personnel. Summaries of reported events must be disseminated in a timely fashion. A structured mechanism must be in place for reviewing repo
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