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An ideal near miss event reporting system includes both mandatory (for incidents with high loss potential) and voluntary, non-punitive reporting by witnesses. A key to any near miss report is the "lesson learned". Near miss reporters can describe what they observed of the beginning of the event, and the factors that prevented loss from occurring.
Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a health care facility; Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility
An analysis of incidents allows safety alerts to be issued to AORN members. AlmostME [83] is another commercially offered solution for near-miss reporting in healthcare. Limits of the industrial safety model Unintended consequences may occur as improvements in safety are undertaken. It may not be possible to attain maximum safety goals in ...
Sentinel events can be caused by major mistakes and negligence on the part of a healthcare provider, and are closely investigated by healthcare regulatory authorities. Sentinel events are identified under The Joint Commission (TJC) accreditation policies to help aid in root cause analysis and to assist in development of preventive measures. The ...
The deadly air collision that killed 67 people in Washington, DC Wednesday night came amid an air traffic control staffing crisis and alarmingly high rates of near-misses on airport runaways.
The Federal Aviation Administration has called for ‘urgent action’ after a series of near-misses at US airports (Getty Images) New York Terminal Radar Approach Control staffing is at just 54 ...
Traditional state-based legal protections for such health care quality improvement activities, collectively known as peer review protections, are limited in scope: They do not exist in all States; typically they only apply to peer review in hospitals and do not cover other health care settings, and seldom enable health care systems to pool data ...
The Pentagon's latest report on UFOs has revealed hundreds of new instances of unidentified and unexplained aerial phenomena -- including a recent near miss involving a commercial plane and a ...