| Description |
Medical errors remain a leading cause of death and poor patient outcomes during hospitalization in the United States (Oyebode, 2013; Rodziewicz & Hipskind, 2019). The Institute of Medicine reported that medical errors result in at least 7,000 deaths and cost 17-29 billion dollars annually (Oyebode, 2013). Healthcare organizations have recognized the importance of including healthcare workers in the process of error identification. Incident reporting systems have been in place since the early 2000s as a way of identifying medical errors in the healthcare arena (De Feijter et al., 2012). Healthcare organizations across the nation use internal self-reporting systems as a critical piece in process improvement and identification of potential threats to patient safety. "To Err is Human: Building a Safer Health System" (2000) states: Voluntary reporting systems are particularly useful for identifying types of errors that occur too infrequently for an individual health care organization to readily detect based on their own data, and patterns of errors that point to systemic issues affecting all health care organizations (p. 87)In addition to reporting actual medical errors and serious safety events, incident reporting has expanded beyond voluntary reporting systems to help prevent errors, including chart reviews, investigation of patient complaints, even prediction of future events based off of past errors. Medication errors are recognized as a form of preventable patient injury, and as such have long been the focus of improvement projects including the fostering of safety cultures in which medication errors can be investigated (Kavanagh, 2017 & Benjamin, 2003). Because most medication errors are considered preventable, the reporting of safety events is important to healthcare organizations always looking to improve quality, processes, and outcomes (Ferracini et al., 2016). While not all safety events lead to permanent or even temporary patient harm, the identification of "near miss" events or process flaws can greatly improve the odds of catching deviances in performance or processes that could eventually lead to serious safety events (Kaplan, 2005). In 2015, Crane et al., writes "near-miss events, or errors that are corrected before a patient is harmed, represent an opportunity to identify and correct flaws that jeopardize patient safety" (452). Using reported near miss events in quality improvement strategies makes the process proactive rather than reactive, hopefully preventing adverse reactions and patient outcomes before they occur. |
