Medical Error Reporting System
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Error Reporting System In Healthcare
Last Updated: August 2014 Voluntary Patient Safety Event Reporting (Incident Reporting) Topics Resource Type Patient Safety Primers Approach to Improving Safety Error Reporting Institutional Reporting More Share Facebook Twitter Linkedin Email
Incident Reporting In Healthcare
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 provide detailed information. Initial reports often come from the frontline personnel directly medication error reporting procedure 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 reports and developing action plans. While traditional event reporting systems have been paper based, technological enhancements have allowed the development of Web-based systems and sy
DataSetsGEO ProfilesGSSGTRHomoloGeneMedGenMeSHNCBI Web SiteNLM CatalogNucleotideOMIMPMCPopSetProbeProteinProtein ClustersPubChem BioAssayPubChem CompoundPubChem SubstancePubMedPubMed HealthSNPSparcleSRAStructureTaxonomyToolKitToolKitAllToolKitBookToolKitBookghUniGeneSearch termSearch Browse Titles Limits reporting medication errors in nursing Advanced Help NCBI Bookshelf. A service of the medical error reporting patient safety and the physician National Library of Medicine, National Institutes of Health.Hughes RG, editor. Patient Safety when an error occurs, which of the following is a productive response? and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Patient Safety and https://psnet.ahrq.gov/primers/primer/13/voluntary-patient-safety-event-reporting-incident-reporting Quality: An Evidence-Based Handbook 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 InformationZane Robinson Wolf;1 Ronda G. Hughes.21 Zane Robinson Wolf, https://www.ncbi.nlm.nih.gov/books/NBK2652/ 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 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 organiza
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of Clinical Oncology. Medical Errors: Focusing More on What and Why, Less on Who Remember, there is nothing you can do to change [the past], but you can use its lessons to improve your future. —Rabbi Abraham J. Twerski, MD Disclosure of medical errors and improvement in patient safety are inexorably linked, and provide one of the strongest reasons to report and disclose errors, including near misses in which no harm comes to the patient. As Rosner et al1 notes, “The paradox of modern quality improvement is that only by admitting and forgiving error can its rate be reduced.” Error reports can be valuable learning tools as well—both for those immediately involved and for the health care community at large. Nevertheless, US health care has not had a good record when it comes to reporting medical errors, even significant ones. For example, 20 states have mandatory reporting systems, but only six have received more than 100 reports in 1999. Yet the Institute of Medicine (IOM; Washington, DC) estimates that more than 1 million preventable adverse events occur each year in the United States, with up to 98,000 being fatal, a figure equivalent to one major airliner crash daily.2,3 Next Section Overcoming Barriers Barriers to error reporting are found at many levels in the health care system. Moskop et al4 assert that US health systems are not generally designed to encourage error recognition, reporting, and remediation. Teaching hospitals have focused on the sequelae of errors rather than teaching ways to prevent them or the value of disclosing them. Physicians' training and attitudes place additional barriers to reporting errors. As the gatekeeper for a patient's care, the physician who commits an error, especially one that harms the patient, may feel deep shame, guilt, and a sense of failure. He or she may believe that disclosing the error to the patient will do irreparable damage to the physician-patient relationship and to the patient's trust in the health care system in general. F