RT Book, Section
A1 Spell, Nathan
A2 McKean, Sylvia C.
A2 Ross, John J.
A2 Dressler, Daniel D.
A2 Brotman, Daniel J.
A2 Ginsberg, Jeffrey S.
SR Print(0)
ID 56191775
T1 Chapter 12. Tools to Identify Problems and Reduce Risks
T2 Principles and Practice of Hospital Medicine
YR 2012
FD 2012
PB The McGraw-Hill Companies
PP New York, NY
SN 978-0-07-160389-8
LK accessmedicine.mhmedical.com/content.aspx?aid=56191775
RD 2024/04/24
AB Every  organization  needs  a  structure  and  a  toolkit  to  support  improving  safety  and  quality.  Since  what  cannot  be  seen  cannot  be  fixed,  robust  identification  of  adverse  events  and  sources  of  risk  (risk  to  patients,  to  staff,  and  to  the  reputation  of  the  organization)  should  be  a  priority  of  every  hospital.  This  chapter  begins  with  discussion  of  structures  and  tools  to  identify  adverse  events  and  risk-prone  conditions.  Once  identified,  the  hospital  and  staff  must  then  determine  the  priority  items  and  which  techniques  will  be  applied  to  reducing  adverse  events  and  risks.  Let  us  define  a  few  terms  for  this  chapter.  Adverse  events  are  instances  of  harm  to  patients  resulting  from  medical  care.  Errors  may  be  characterized  as  resulting  from  a  flawed  plan  or  from  failure  of  a  plan  to  be  completed  as  intended.  Not  all  adverse  events  result  from  error,  and  not  all  errors  result  in  harm.  A  near  miss  is  an  error  or  system  failure  that  is  either  intercepted  before  reaching  the  patient  or  causes  no  harm  if  it  does  reach  the  patient.  Risk  reduction  efforts  may  focus  on  error  prevention  or  on  harm  prevention.  This  chapter  will  not  promote  one  approach  over  the  other,  as  these  principles  and  tools  apply  to  both.