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