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Preventing Errors for Healthcare Professionals: Summary
2. IHI's Trigger Tool : ○ Contains 53 triggers to identify potential adverse events during hospitalization ○ Widely used for adverse event identification and analysis However, both tools have limitations: ○ They are retrospective (identifying events after harm occurs) ○ Require additional review to confirm preventable adverse events ○ May not capture all preventable adverse events This highlights the ongoing challenge of comprehensive error identification and the need for multiple approaches to capture and analyze medical errors effectively. Sentinel Event LEARNING TIP!
• Maternal complications : ○ Maternal death during birth ○ Severe maternal morbidity requiring intensive intervention • Other serious events : ○ Severe neonatal hyperbilirubinemia ○ Fire/smoke during patient care ○ Equipment-related incidents Importantly, not all sentinel events result from errors, and not all errors lead to sentinel events. MANDATES WITHIN THE STATE OF FLORIDA Florida has specific requirements for medical error prevention and reporting: Continuing Education: All healthcare professionals must complete 2 hours of approved training on Prevention of Medical Errors for license renewal. Mandatory Reporting: • Sentinel events must be reported (unlike voluntary TJC reporting) • Hospitals must implement risk management programs with state oversight • The Florida Comprehensive Medical Malpractice Act of 1985 mandates that each licensed hospital must implement a risk management program with state oversight and an internal incident-reporting system. Oversight is provided by the State of Florida Agency for Health Care Administration (AHCA). Each licensed hospital is required to hire a risk manager who is responsible for the implementation and management of the risk management program. Reportable Adverse Incidents Include: • Death or serious injury (brain/spinal damage, permanent disfigurement) • Wrong-site/patient/procedure surgeries • Unplanned surgical repairs • Retained surgical objects • Conditions requiring transfer to higher levels of care
A sentinel event, as defined by The Joint Commission (TJC), is any unexpected occurrence in a healthcare setting that results in death or serious physical/ psychological injury unrelated to the natural course of a patient's illness.
These events require a root cause analysis (RCA) and include: • Critical incidents : ○ Patient suicide (in facility or within 72 hours of discharge) ○ Unexpected full-term infant death ○ Patient abduction or elopement leading to harm ○ Wrong family infant discharge ○ On-site violence (rape, assault, homicide) ○ Major medical errors: ■ Wrong blood transfusion reactions ■ Wrong procedure/patient/site surgeries ■ Retained surgical objects ■ Radiation errors
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