Αποτελέσματα Αναζήτησης
31 Μαΐ 2016 · Near miss: an unsafe situation that is indistinguishable from a preventable adverse event except for the outcome. A patient is exposed to a hazardous situation, but does not experience harm either through luck or early detection.
29 Μαρ 2023 · The Joint Commission defines a sentinel event as a patient safety event that results in death, permanent harm, or severe temporary harm. Sentinel events are debilitating to both patients and health care providers involved in the event.
The direct, analytical pathway, which near-miss and adverse event systems have in common, is based on collecting incident data; analyzing root causes; and acting upon the most important causes, thereby gradually improving the system and achieving better (safety) performance.
The aim of this study was to evaluate the current status of handling and learning from sentinel events (SEs) in Dutch academic hospitals and to develop a basis for the first steps in a joint and transparent approach to improve learning from SEs. Design.
Mandatory reporting systems, usually enacted under State law, generally require reporting of sentinel events, such as specific errors, adverse events causing patient harm, and unanticipated outcomes (e.g., serious patient injury or death.
Capturing information about events, including hazardous conditions, near misses, adverse events, and sentinel events, helps an organization learn and improve continuously while creating safer care for patients and safer conditions for staff. 6
This study describes nurses' experiences with sentinel events in hospital settings, including intensive care, medical-surgical, long-term care, psychiatric, and Alzheimer units.
