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Published on: 1/27/2004
Last Visited: 1/27/2004
"The reality is that when somebody is killed, it's pretty hard to sweep it under the rug," said Kasey Thompson, director, Center on Patient Safety at ASHP."More and more organizations are coming forward to admit their role in errors."
What institutions should do after an error and what they actually do are not always the same, Thompson explained.In theory, the patient and patient family must be informed as soon as an error is recognized, he said.The Joint Commission on Accreditation of Healthcare Organizations must also be informed if the error results in a fatality or serious adverse effect.State and local health authorities must be notified in some jurisdictions.
If the error is serious, Thompson continued, JCAHO requires hospitals to conduct a root cause analysis to determine the reasons for the error.The hospital must then outline steps it will take to prevent similar errors.JCAHO evaluates both the analysis and the corrective measures, Thompson said, adding that analyzing and correcting one error is not enough.Institutions need to examine their systems before anything goes wrong to find and correct potential problems.
The practice is called failure mode effects analysis, Thompson explained.