Incident Reporting System : Accident Reporting Mechanism Essay

Healthcare workers are not the only ones fearful of exposing medical errors. The medical institutes themselves operate behind a wall of silence. The IOM first recommended a national medical error reporting system in 1999 and despite attempts by then President Clinton, the American Medical Association and the American Hospital Association successfully lobbied against it (Dyess, 2009). As of 2009, only 20 states have a mandatory medical error reporting system and only a fraction of estimated

The National Incident Based Reporting System (NIBRS), is the system that police use to report crime data. The data includes; the nature or type of the specific offense, the characteristics of victims and offender, the type and value of property stolen and/ or recovered, and characteristics of persons arrested with crime incidents. Incident-based data provides a large amount of criminal information. This is organized in complex, it reflects the different aspects of a crime incident.

The "naming, blaming, and shaming" approach to dealing with errors has hindered medical error reduction, yet it is the most commonly used approach to addressing errors in health care (koop,1999).

New innovations are being created every year to help improve and protect patients from reckless and preventable errors. As healthcare providers, it is our duty to provide care ethically and to do no harm to our patients. On the contrary, “the culture of cover-up” still continues to exist today and although technology and informatics has progressively increased quality care, it has not completely eradicated errors. Integrity is the key component for every healthcare provider, along with other characteristics. Therefore, disclosing medical errors with our patients is imperative and our patients and their families deserve to know what occurred during their time of care. Technology is not able to prevent every mishap that causes patients harm (Gibson & Singh, 2003). On the other hand, communication and learning from the mistake can. As Gibson and Singh (2003) so eloquently stated, “…wise people learn form their mistakes, and those who don’t are bound to repeat

Within the public safety and criminal justice field, leaders depend on out stats from our reporting system about crime in their area or state. This data can be located on either the National Incident-Based Reporting System (NIBRS) or the Uniform Crime Reports (UCR) system that is published by the Federal Bureau of Investigation (FBI). These reports are helpful not only to public safety and the criminal justice field, but also to researchers. The reports can help a researcher gain ideas of areas that need to be studied (e.g. does a defendant’s neighborhood influence criminal activity, etc.). Within this paper it will discuss research that can help us to identify what type of

I agree with you that under reporting medical errors compromise patient safety.  It is important to report mistakes not only to appropriately follow up with the affected patient but also the improve  the protocol if its needed.  I also think that fear plays a huge part on nurses not reporting errors. I think that they are afraid of the consequences or penalties for the errors. I enjoy reading your post.

In 2011, over 3,800 of these “never events” where reported to the Joint Commission (psnet, n.d.). Being an Administrator in a hospital setting, it is import to know what SRE’s mostly occur. Many of the SRE’s reported in 2011 were linked to surgical events such as wrong-site surgery, air embolism, death or disability due to medication errors, patient suicide and environmental events such as fires, which can harm anyone in the facility (psnet, n.d.). 8.2% of the serious reportable events reported to the joint commission where medication errors, nearly 600 reports are medication errors. This happens when a patient dies or is seriously injured due to a medication error such as being administered the wrong drug or the wrong dose, it was given to the wrong patient, at the wrong time or wrong rate or had the wrong preparation, or wrong route of administration (psnet, n.d.). Mediation errors are the most important or relevant to hospital setting

The most common adverse event that jeopardize patient safety is patient falls, or for documentation purpose, patient found on the floor. The most common preventable adverse event that jeopardize the nurse accountability is patient falls. In my four years of nursing I have had to complete one patient fall incident report, but I have assisted in the documentation of at least four, which was five to many patients fall. Morse fall scale is the fall risk assessment commonly used in the hospital setting. My plan is to shine the light on fall prevention intervention by taking the Morse fall scale 2-steps farther. What nurses may not know is, inpatient falls are the liability of the hospital and not reimbursed by Center for Medical and Medicaid Service (Given, Given & Spoelstra, 2012).

Furthermore, after the patient had the fall, the patient’s condition and status slowly deteriorated. After an incident such as a fall in this case, it is part of any hospital policy to document the episode and all the events that has led to the fall. There was insufficient documentation even though the nurses were able to conduct their assessment on the patient.

In 2012 World Health Organization reported an estimate of one in ten people being subject to harm whilst hospitalized in developed countries. Patient safety is the epitome of healthcare as this is indicated by the ongoing systematic reviews by health organizations worldwide. Nurses duty of care to patients is ensuring and maintaining patient safety during their admission in hospital (Ammouri, et al 2012). Failure of effective handoff/handover communication between healthcare providers has been found to be the cause of approximately 80% of serious medical errors (Huang et al, 2010). This article will focus on communication between caregivers, lack of leadership and teamwork, lack of reporting systems, inadequate analysis of adverse events and inadequate staff knowledge about

Major patient safety events are rarely a single error event. The events are usually a series of interrelated omissions or system errors. The following errors were noted:

The last aspect in increasing public awareness involves changing the mindset of the people from individual problem to systems problem. Most people believe that medical errors are the result of the failures of individual providers. The public believes that possible solutions to medical errors are to keep health professionals with bad track records from providing care and give better training to health professionals. The IOM report stated that it is a systems problem. They emphasized that most of the medical errors are systems related and not attributable to individual negligence or misconduct. The key to reducing medical errors is to focus on improving the systems of delivering care and not to blame individuals. Health care professionals are simply human and, like everyone else, they make mistakes. Research has shown that system improvements can reduce the error rates and improve the quality of health care. A 1999 study indicated that including a pharmacist on medical rounds reduced the errors related to medication ordering by

The result of under-reporting errors is inaccurate statistics of medical errors. As a result it prevents the medical community to implement solutions or better practice to prevent this errors from happening

Incident reporting is very crucial for improving the safety and quality of patient care. It allows healthcare organizations to investigate the contributing factors of adverse events and help them to develop potential solutions. In my workplace, we use an incident report form and Situation, Background, Assessment, and Recommendation (SBAR) form, where all the information related to an incident including possible cause are incorporated and then forms are submitted to the unit manager. Unit manager reports an incident to the director of nursing (DON) and DON and the facility administrator start investigation and interventions. Finally, a healthcare worker who was involved in an incident should take in-service education in that particular area

There is no need in reinventing the wheel, and Iezzoni, DesRoches and Vogeli (2012) could not use a better description of what is patient center care. In essence, they describe the shift to patient care as a “movement towards collaborative care, empathic listening, shared decision making, and culturally competent care that reflect a growing understanding of the potentially therapeutic implications of patient-physician communication” (Iezzoni, DesRoches and Vogeli, 2012 pg. 384). However, hospital life does not always allow the time for this relationship to run its course for many reasons. Therefore, as a member of the hospital leadership team, I would encourage disclosure of medical errors by implementing an error disclosure training, promoting