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e. A significant event audit (SEA), also known as significant event analysis, is a method of formally assessing significant events, particularly in primary care in the UK, with a view to improving patient care and services. To be effective, the SEA frequently seeks contributions from all members of the healthcare team and involves a subsequent ...
The Patient Safety Reporting System (PSRS) is a program modeled upon the Aviation Safety Reporting System and developed by the Department of Veterans Affairs (VA) and the National Aeronautics and Space Administration (NASA) to monitor patient safety through voluntary, confidential reports. [78]
Near miss (safety) A near miss, near death, near hit, close call is an unplanned event that has the potential to cause, but does not actually result in human injury, environmental or equipment damage, or an interruption to normal operation. [citation needed] OSHA defines a near miss as an incident in which no property was damaged and no ...
The Health Services Safety Investigations Body (HSSIB) is a fully independent arm's length body of the Department of Health and Social Care. HSSIB came into operation on 1 October 2023. It investigates patient safety concerns across the NHS in England and in independent healthcare settings where safety learning could also help to improve NHS care.
Bow-tie diagram. A bow-tie diagram is a graphic tool used to describe a possible damage process in terms of the mechanisms that may initiate an event in which energy is released, creating possible outcomes, which themselves produce adverse consequences such as injury and damage. The diagram is centred on the (generally unintended) event with ...
Goal 1: Identify patients correctly. Goal 2: Improve effective communication. Goal 3: Improve the safety of high-alert medications. Goal 4: Ensure safe surgery. Goal 5: Reduce the risk of health care-associated infections. Goal 6: Reduce the risk of patient harm resulting from falls. [2][4]
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A sentinel event is "any unanticipated event in a healthcare setting that results in death or serious physical or psychological injury to a patient, not related to the natural course of the patient's illness". [1] Sentinel events can be caused by major mistakes and negligence on the part of a healthcare provider, and are closely investigated by ...