1 / 13

Near Miss-- Early Warning System Sarah Tackett, CPHQ, FNAHQ

Near Miss-- Early Warning System Sarah Tackett, CPHQ, FNAHQ. IOM Findings. Serious Problem Bad Systems Loss of Public Trust Safety a Priority. Deadly Secret?. 3700. 4100. 8400. 16,600. 41,200. 98,000. Source: National Safety Council; Philadelphia Inquirer, Leape, M.D.

elmira
Download Presentation

Near Miss-- Early Warning System Sarah Tackett, CPHQ, FNAHQ

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Near Miss-- Early Warning System Sarah Tackett, CPHQ, FNAHQ

  2. IOM Findings • Serious Problem • Bad Systems • Loss of Public Trust • Safety a Priority

  3. Deadly Secret? 3700 4100 8400 16,600 41,200 98,000 Source: National Safety Council; Philadelphia Inquirer, Leape, M.D.

  4. Air Force/AFMCNear Miss Experience • Policy to Report • Near Misses/Adverse Events • Opportunities in the Near Misses • Six Months • Willingness to Report • Willingness to Investigate/Fix

  5. AFMC Medical Errors Pilot TestApr-Sep 00

  6. AFMC Medical Errors Pilot TestApr-Sep 00

  7. AFMC Medical Errors Pilot TestApr-Sep 00

  8. AFMC Medication ErrorsApr-Sep 00

  9. Medication Errors • Microzide--Micronase • Codeine--Morphine • 12.5mg demerol--125 mg demerol • 8mg decadron--10mg verses • .5mg prepedril gel--20 prostin suppository • .25cc terbutaline--.25cc methergine • Vancomycin, Flagyl, Vantim, Bactrim & Motrin

  10. Military Health SystemVs IOM Report • Stratify this data (loosely) over 500 MTFs in the MHS • Errors per MTF = • 4.5 month/<1 patient harmed • Monthly errors in DOD = • 2,230 per month/ 315 patients harmed • Annual errors in DOD = • 26,760 per month/3,780

  11. Creating A SafetyCulture • Current approach blames providers and promotes secrecy • New approach accepts that humans make mistakes, focuses on systems and promotes openness • Importance of looking at near misses • Education and communication are crucial

  12. New Look--Systems Safety • Improve reliability & safety • continuously learn about the system • Ability to investigate • Understand the full story • Move beyond asking who to blame • Culture that talks about failure

  13. Questions?

More Related