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chapter 10 | Quality and Safety 147 CikguOnline
Not all errors lead to patient harm or to an systems (Rosenthal & Booth, 2005). In addition,
adverse event. Each type of event can be studied to the Food and Drug Administration (FDA) man-
glean data used to improve safety. dates reporting of serious harm or death (adverse
events) related to drugs and medical devices. Failure
■ Near miss. A near miss is an error that results in
to report mandatory requirements may lead to fines,
no harm or very minimal patient harm (IOM,
withdrawal of participation in clinical trials, or loss
2000, p. 87). Near misses are useful in identify-
of licensure to operate.
ing and remedying vulnerabilities in a system
The Joint Commission relied on root cause
before harm can occur.
analysis from each sentinel event. Root cause analy-
■ Adverse event. An adverse event is injury to a
sis is the process of learning from consequences.
patient caused by medical management rather
The consequences can be desirable, but most root
than an underlying condition of the patient
cause analysis deals with adverse consequences. An
(IOM, 2000). The IOM reports have highlight-
example of a root cause analysis is a review of a
ed the prevalence of errors, especially preventa-
medication error, especially one resulting in a death
ble adverse events. Adverse events have been
or severe complications. Principles of root cause
classified into four types (see Box 10-7).
analysis include:
■ Accident. An accident is an event that involves
damage to a defined system that disrupts the 1. Determine what influenced the consequences,
ongoing or future output of that system. i.e., determine the necessary and sufficient
Accidents occur when multiple systems fail and influences that explain the nature and the mag-
tend to be unplanned or unforeseen. Accidents nitude of the consequences.
provide information about systems. 2. Establish tightly linked chains of influence.
3. At every level of analysis, determine the neces-
Error Identification and Reporting sary and sufficient influences.
4. Whenever feasible, drill down to root causes.
Nurses are on the front line in identifying and
5. Know that there are always multiple root causes.
reporting errors. However, many errors are not
reported or go undetected. Providers and organiza- The Joint Commission also developed the
tions may fear blame or punishment for mistakes International Center for Patient Safety, which
or errors. establishes National Patient Safety Goals each year
and publishes Sentinel Event Strategies. Box 10-8
Developing a Culture of Safety
To achieve safe patient care, a culture of safety must
exist. Organizations and senior leadership must
box 10-8
drive change to develop a culture of safety—a
blame-free environment in which reporting of Joint Commission International Center
errors is promoted and rewarded. A culture of for Patient Safety
safety promotes trust, honesty, openness, and trans- 1. Sets patient safety standards
parency. Teamwork and involvement of the patient 2. Implements and oversees sentinel event policy and
advisory group
contribute to promoting a culture of safety. When
3. Publishes Sentinel Event Alert newsletter and quality
a culture of safety exists, individual providers do check reports
not fear reprisal and are not blamed for identifying 4. Sets yearly national patient safety goals
or reporting errors. Reported errors provide data 5. Developed the universal protocol related to surgical
and information necessary to understand why or procedures
6. Evaluates organizations’monitoring of quality of care
how the error occurred, thus improving care and
issues
preventing harm. 7. Conducts patient safety research
Event-reporting systems hold organizations 8. Provides patient safety resources
accountable and lead to improved safety.Mandatory 9. Supports the Speak Up program
reporting systems are operated by regulatory agen- 10. Involved with patient safety coalitions and legislative
efforts
cies and have a strong focus on errors associated
Adapted from Joint Commission on Accreditation of Healthcare
with serious harm or death. As of 2005, 24 states
Organizations (JCAHO), accessed November 26, 2005, from
had either mandatory or voluntary reporting jcpatientsafety.org