standards include professional practice standards and practice requirements imposed by accreditation.
Near Miss Safety Events
An error may cause varying levels of harm to a patient. A near miss safety event occurs when the safety event doesn't reach the patient because it is caught by chance or because the process was engineered with a detection barrier. For example, Ms. Johnston and Ms. Johnsen may both be hospitalized on the same nursing unit. The nurse may accidently bring Ms. Johnston's medications to Ms. Johnsen. By properly identifying the patient using two unique identifiers, this error can be identified before causing harm to the patient. Nurses often fail to report Near Misses, rationalizing that no one was hurt. However, near miss safety events serve as an early warning system of something that could go wrong. By reporting near miss safety events, health care organizations can work on improving processes so that no one else makes the same error.
Precursor Safety Events
Precursor safety events occur when the health care error reaches the patient and results in no harm or minimal detectable harm. For example, the nurse may do a finger stick to check a blood sugar for Ms. Johnston when it was ordered for Ms. Johnsen. The error has reached the patient but has resulted in minimal harm, in this case a finger stick. Like near miss safety events, precursor safety events should be reported so that they can be used to improve care.
Adverse Events and Serious Events
Adverse events or serious safety events occur when the error reaches the patient and results in moderate to severe harm or even death.
Sentinal Events
Sentinel events are a subcategory of adverse events. A sentinel event is a patient safety event that is not primarily related to the natural course of the patient's illness or underlying condition, reaches the patient, and results in death, permanent harm, or severe temporary harm (TJC, January 2018). For example, imagine that the nurse administered a unit of packed red blood cells intended for Ms. Johnston to Ms. Johnsen. The results could be catastrophic, and the health care team would need to take immediate action to save Ms. Johnsen's life. After the immediate crisis is handled, sentinel events must be carefully investigated. Corrective action plans must be created to reduce risk and prevent harm for future patients.
TJC is an independent, not‐for‐profit group in the United States that provides accreditation for many hospitals and other health care organizations. TJC publishes a list of the most frequently occurring sentinel events, summarized in Table 4.1. The reporting of sentinel events is voluntary and represents only a small proportion of actual sentinel events.
Table 4.1 Five Most Frequent Sentinel Events, 2014 through 2017 (TJC, January 2018)
| Event | Definition | Number of Reported Events |
|---|---|---|
| Unintended Retention of a Foreign Body | An unintended retention of a foreign body is defined as the retention of a foreign object in a patient after surgery or other procedure. | 481 |
| Wrong‐patient, wrong‐site, wrong‐procedure | A wrong‐patient procedure occurs when the procedure is performed on the incorrect patient. A wrong‐site procedure involves operating on the wrong side of a patient. A wrong procedure occurs when an incorrect procedure is performed on a patient. | 409 |
| Fall | A fall sentinel event is defined as an unplanned descent to the floor resulting in death, permanent harm, or severe temporary harm. | 404 |
| Suicide | A suicide sentinel event is defined as intentionally killing oneself in a healthcare setting. | 361 |
| Delay in treatment | A delay in treatment sentinel event is when a patient does not get any type of treatment (medication, lab test, etc.) that was ordered for them in the time frame in which it was supposed to be delivered, and the delay results in death, permanent harm, or severe temporary harm. | 290 |
| Total number of reported sentinel events | A subcategory of Adverse Events, a Sentinel Event is a patient safety event (not primarily related to the natural course of the patient's illness or underlying condition) that reaches a patient and results in any of the following: Death; Permanent harm; or Severe temporary harm. | 3,326 |
Source: The Joint Commission (January 2018). Patient Safety Systems. Retrieved from https://www.jointcommission.org/assets/1/6/PS_chapter_HAP_2018.pdf.
The Anatomy of an Error
Active Errors
Errors are often noticed at the point of care, where nurses and other clinicians interact with patients. This is considered the “sharp end” of a triangle (Cook & Woods, 1994). These errors are considered active errors because they occur at the point of interface between humans and a complex system. Clinicians often blame themselves when errors happen. However, their work with patients is influenced by many factors and decisions made before an actual error occurs. These factors and decisions are considered the “blunt end” of the triangle.
Latent Errors
Latent errors are hidden problems within health care systems that contribute to adverse events (Agency for Healthcare Research and Quality [AHRQ], 2018a, 2018b). For example, policies and procedures within an organization may be inaccessible, difficult to understand, or inaccurate. Work processes might be confusing and patient handoffs may be rushed and inadequate. The environment may be cramped and noisy, making it difficult to concentrate. Technology may fail or be cumbersome to use. Individuals may blame others rather than taking personal responsibility. The culture of the hospital might hinder a nurse's ability to speak up about safety concerns. All of these “blunt end” factors may contribute to an error at the “sharp end,” where clinicians interact with the patient.
James Reason (1997) proposed the Swiss Cheese model, shown in Figure 4.1, to illustrate how errors occur. The model suggests that every step in a process has the potential for error. The holes in the Swiss cheese represent opportunities for a process to fail, and each slice is a defensive layer to prevent an error in the process. An error may pass through a hole in one layer but in the next layer, the hole is in a different spot and the layer catches the error before it reaches the patient. More layers of cheese and smaller holes allow more errors to be stopped or caught. When the holes in the Swiss cheese line up, an error occurs.
Source: © Used with permission granted from Patti Ludwig‐Beymer.
High Reliability Organizations
Building an HRO is a cultural transformation designed to ensure safe practices and