Editor's note: This is the inferio...

Editor's note: This is the inferior of a two-part series onward incident reports. Part I, which was published in the August 2003 issue of the AORN Journal explains the degrees for reporting an incident. Risk management and legal liabilities were discussed and question s that exist with incident reports were identified.

For years, incident reporting has been cast in a negative light. Reporting is viewed as primitive by way of employees who commit an infraction, as a horrible disease to be ignored through physicians, and as a legal collection of vapor looming overhead by administrators. Accidents inevitably come into view because people, by nature, are not infallible. The quantity and magnitude of errors can be minimized, however, according to designing and implementing systems that make it les likely for an error to present itself Part I of this series focused onward today's health care climate and the various prices associated with errors. The spell incident report was defined and discussed, as was the meaning of incident reports, situations that are considered reportable, gradations to report incidents, and the legal liability issues involved. Although there are numerous point to be solved [i]or[/i] settleds involving the incident reporting proces these issues can be mitigated with clear unless dynamic guidelines that are modifiable as situations change.

This article focuses forward using a systems approach to eradicate question at issues with incident reporting. Continuous quality improvement, a logical inferior step after an incident report has been initiated, is an important ongoing proces that helps make secure improvement in the quality of patient care. The article decides with a discussion on impressed signs of errors and suggestions to restore errors.

arrangements APPROACH

Systems approaches assess the structural and functional ways in which an organization operates, as well as to what degree the people at that organization interact. The internal and external influences in succession the system also are studied. Individual practitioners who work in the arrangement learn behaviors that are acceptable to the hypothesis (eg, socially embedded knowledge, notions of what constitutes being proper techniques required for mastering a skill). This is called practice responsibility. Learning is cumulative and shared with others, which reshapes the organization's a whole over time. (1) A list of words associated with incident reporting and bodys analyses are defined in Table 1

about industries (eg, the aviation industry) occupy various approaches to identify plan or latent errors and glaring hazards. Systems approaches allow the industry to be alerted to potential or actual errors. The health care industry merely recently has embarked on similar efforts to increase patient safety. (2) long can be learned by analyzing data after an error has been committed. All near misses and adverse consequences in a health care facility should be analyzed to discover where improvements can be made in the delivery connected view to reduce the likelihood of similar circumstances occurring. (3) "Accident causation is more likely to be thwarted in changing the system than the individual." (4(p206)) Health care professionals should be careful, vigilant, and held responsible for their actions, if it were not that blaming them for errors does little to make the regularity safer and prevent someone other from committing the same error. (3)

present theories of quality improvement focus onward the average worker, not upon the outlier. Typically, nurses are caring and practice at their best, responding to constructive processe that emphasize making a suitable clinician better. Given this prospect it is understandable that the theory of bad apples (ie, the belief that quality is best achieved from discovering bad apples and removing them from the lot) should not be useed (5)

HUMAN FACTOR ANALYSIS. Human factor analysis is the investigation of human performance and the error proces (ie, causes, circumstances, conditions, other associated factors). The goal of human factor analysis is to improve human-system interfaces according to designing better systems and processe Interrelationships between persons the tools they use, and the environment in which they live and work are the variables that are studied. (467)

Human factor analysis focuses in succession improving the human-system connection on simplifying and standardizing procedures, including redundancy for backup, improving communication and coordination between teams, and redesigning equipment to improve the human-machine interface. couple approaches have been used in human factor analysis. The first approach is critical incident analysis, which examines a significant or pivotal affair to analyze where the scheme broke down, why an incident occurr and the circumstances surrounding the incident. The inferior approach is called naturalistic decision making, in which the natural work setting (ie, environment) is evaluated in seasons of its effect on the decisions made at people. This analysis uncovers the factors weighed and processe used in making decisions given ambiguous information in subordination to time pressures. (3) Numerous industries and the military use this approach in their investigation of accidents. The focus is in succession pre-existing organizational factors rather than forward the individual who made the error. the same noted industrial quality manager published suggestions for self-reporting in industry more than 10 years ago. These suggestions include