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Certified Legal Nurse Consultant

Posted on April 10, 2016 at 7:05 PM Comments comments (57)

Introduction to terms and definitions related to patient safety as cited by the National Patient Safety Foundation

Patient Safety is defined as “Creating a world where patients and those who care for them are free from harm”.

Communication breakdown – related to treatment plan and inaccurate or lack of communication between the patient and clinician or between two clinicians

Communication error– missing or wrong information or misinterpretation of information

Critical incident – human error or equipment failure that lead to or could have lead to an undesirable outcome

Error – Failure to complete a planned action or use of wrong plan to achieve a goal; problem of practice, products, procedures and systems

Error of Negligence – Error due to inattention or lack of obligatory effort

Error of Omission – The failure to administer an ordered dose of medication to a patient before the next scheduled dose is due; excludes patients who refuse to take a medication or a decision not to administer.

Error of commission – An error which occurs as the result of action taken

Individual error – Those deriving primarily from deficiencies in the clinician’s own knowledge, skill and attentiveness

Near miss – An event or situation that could have resulted in an accident, injury or illness but did not, either by chance or through timely intervention

Negligence – Care that fell below the standard expected of physicians {clinicians} in their community; Failure to use such care as a reasonably prudent and careful person would use under similar circumstances

Preventability – Implies that methods for averting a given injury are known and that an adverse event results from failure to apply that knowledge

Quality of Care – Degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge

Reportable occurrences – An event, situation or process that contributes to a patient or visitor injury or degrades our ability to provide optimal patient care; designated by severity: sentinel events, patient or visitor injuries (adverse events), near misses and safety concerns

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According the the National Patient Safety Foundation transparency is the key to reducing patient harm caused by health care providers. It is the standard of practice to report all errors, near misses and accidents and injuries in order that a root cause analysis may be done.  The importance of sharing information between team members, with family members and even other organizations is highly regarded as a method to help others avoid making the same mistakes. If you have a case where the incident that caused the injury or damage is not documented in the records, made a part of the care plan and reported to the people who are involved in your client's care to include the patient, family, other team members and the doctor then there is already a deviation from the standard of care. You should not have to search records for hours and hours looking for one or two little statements about an incident.