Definition+of+Medical+Error,+Adverse+Event,+Sentinel+Event

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=Medical Error = =Adverse Event =
 * ==Definition ==
 * errors or mistakes committed by health professionals which result in harm to the patient
 * Diagnostic errors
 * Medication errors: errors in the administration of drugs and other medications
 * Errors in the performance of surgical procedures,
 * Errors in the use of other types of therapy, in the use of equipment, and in the interpretation of laboratory findings
 * Differentiated from malpractice in that the former are regarded as honest mistakes or accidents while the latter is the result of negligence, reprehensible ignorance, or criminal intent
 * November 1999, the Institute of Medicine (IOM) released a report ("Err is Human: Building A Safer Health System") estimating that as many as 98,000 patients die annually from medical errors
 * Hospital errors rank between the 5th & 8th leading cause of death in the US
 * Serious medication errors occur in the cases of 5-10% of patients admitted to hospitals
 * National Patient Safety Foundation by the American Medical Association
 * Non-punitive sentinel events reporting system by the Joint Commission for the Accreditation of Healthcare
 *  Organizations
 * <span style="font-family: Arial,Helvetica,sans-serif;">Veterans Health Administration and other organizations have focused new attention to monitoring and correcting human errors
 * <span style="font-family: Arial,Helvetica,sans-serif;">Agency for Healthcare Research & Quality [|(http://www.ahrq.gov/)] is a branch of the U.S. Department of Health & Human Services
 * ==<span style="font-family: Arial,Helvetica,sans-serif;">Definition ==
 * <span style="font-family: Arial,Helvetica,sans-serif;">an adverse event is any undesirable experience associated with the use of a medical product in a patient.
 * ===<span style="font-family: Arial,Helvetica,sans-serif;"> Reportable outcomes: ===
 * <span style="font-family: Arial,Helvetica,sans-serif;">Death
 * <span style="font-family: Arial,Helvetica,sans-serif;">Life-threatening event
 * <span style="font-family: Arial,Helvetica,sans-serif;">Hospitalization (initial or prolonged)
 * <span style="font-family: Arial,Helvetica,sans-serif;">Disability or permanent damage
 * <span style="font-family: Arial,Helvetica,sans-serif;">Congenital anomaly/birth defect
 * ===<span style="font-family: Arial,Helvetica,sans-serif;">Range of Adverse Events ===
 * <span style="font-family: Arial,Helvetica,sans-serif;"> Grade 1: mild
 * <span style="font-family: Arial,Helvetica,sans-serif;"> Grade 2: moderate
 * <span style="font-family: Arial,Helvetica,sans-serif;"> Grade 3: severe
 * <span style="font-family: Arial,Helvetica,sans-serif;"> Grade 4: life-threatening or disabling
 * <span style="font-family: Arial,Helvetica,sans-serif;"> Grade 5: death-related

=<span style="font-family: Arial,Helvetica,sans-serif;">Sentinel Event =
 * ==<span style="font-family: Arial,Helvetica,sans-serif;">Definition ==
 * <span style="font-family: Arial,Helvetica,sans-serif;">“unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof”
 * <span style="font-family: Arial,Helvetica,sans-serif;">Called “sentinel” because signal the need for immediate investigation and response
 * <span style="font-family: Arial,Helvetica,sans-serif;">Joint Commission points out that the terms ”sentinel event” & “medical error” are not synonymous
 * ==<span style="font-family: Arial,Helvetica,sans-serif;">Goal of Sentinel Event Reporting & Analysis ==
 * 1) <span style="font-family: Arial,Helvetica,sans-serif;">To have a positive impact in improving patient care, treatment, and services and preventing sentinel events
 * 2) <span style="font-family: Arial,Helvetica,sans-serif;">To focus attention of a hospital that has experienced a sentinel event on understanding the factors that contributed to the event (such as underlying causes, latent conditions and active failures in defense systems, or organizational culture), and on changing the hospital's culture, systems, and processes to reduce the probability of such an event in the future
 * 3) <span style="font-family: Arial,Helvetica,sans-serif;">To increase the general knowledge about sentinel events, their contributing factors, and strategies for prevention
 * 4) <span style="font-family: Arial,Helvetica,sans-serif;">To maintain the confidence of the public and accredited hospitals in the accreditation process
 * ==<span style="font-family: Arial,Helvetica,sans-serif;">Root Cause Analysis ==
 * <span style="font-family: Arial,Helvetica,sans-serif;">Root cause analysis is a process for identifying the factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event. A root cause analysis focuses primarily on systems and processes, not on individual performance leading to:
 * <span style="font-family: Arial,Helvetica,sans-serif;">Action
 * <span style="font-family: Arial,Helvetica,sans-serif;">Survey Process

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