Editor's note: This is the first of...

Editor's note: This is the first of a two-part series onward incident reports. Part II, which is scheduled for the August 2003 issue of the AORN Journal will discuss correction processe and in what manner to reduce errors.

Horrible headlines in the mass media about medical errors are rampant these days. Everyone has read or heard about the unsuitable surgery being performed on a child or the improper side of a brain being operated onward by a neurosurgeon. What about the patient who died from an overdose of chemotherapy? These stories captivate family and send chills down their spines because that patient could have been them or a family member. (1)

Patients today are savvy, educated consumer who are mattered about the potential for acquiring an infection, the flush of care they receive, and the qualifications of their health care providers. They believe that chiefly medical errors are the come of the carelessness or negligence of their health care providers, whom they believe to be overworked, worried, or strained (2) Most Americans, however, do not understand completely the breadth of health care issues. Health care today is a involved system comprised of numerous intricate parts that interact with multiple other parts in unexpect ways. Various evens of specialization and interdependencies exist in institutions. This places health care facilities at high risk for accidents. (13)

couple large studies of adverse terminations were conducted--one in Colorado and Utah and the other in novel York. They found that 29% of adverse results occurred during Colorado and Utah hospitalizations and 37% occurr during of the present day York hospitalizations. Death occurred 66% of the time in the Colorado and Utah issues and 13.6% of the time in the modern York events. In both studies, more than 50% of adverse consequences resulted from medical errors that could have been hindered These results extrapolated to the United States imply that at least 44000 Americans die each year as a outcome of medical errors, but this number may be as high as 98000 "More the community die in a given year as a outcome of medical errors than from motor vehicle accidents (43458) breast cancer (42297) or AIDS (16516)" (1(p22))

The estimated total national price of preventable medical errors resulting in injury, which includes dissipated income and US household production, disability, and associated health care richnesss is $17 billion to $29 billion annually. Health care require to be paid [i]or[/i] undergones represent more than half of this number (ie, $85 billion to $144 billion). (2) In addition to the monetary perspective, medical errors also decrease the trust that persons have in the health care plan and diminish satisfaction noted by the agency of both patients and health care professionals. Physical and psychological discomfort accompany longer hospital stays or disability when errors come into one's head Institutions incur poor publicity, damaged reputations, and financial liability from medical errors. Health care professionals pay with los of morale and increased frustration at their inability to provide the best care possible. In addition, employer and society as a whole pay in bourns of lost worker productivity, reduc educate attendance by children, and poorer health of the population. (14)

Accidents inevitably occur--people in all lines of work make errors. Errors can be obstructed however, by designing systems that make it difficult for tribe to make mistakes and easy for family to do the right thing. A positive approach to risk containment and superintend including learning from past errors, forms risk. When near misses come into one's head instead of being thankful nothing negative happened, fosters should question what could be learned from the issue to prevent future occurrences. This proactive stance is supported by way of the notion that to obstruct is cheaper than to healing Understanding why errors and near misses happen helps nurses improve patient safety because they learn from previous mistakes. Identifying and correcting classification errors results in decreased

* personal and facility risk liability,

* regulatory sanctions,

* negative publicity, and

* harm to patients.

Although it may be human nature to make mistakes, it also is human nature to create solutions, discover alternative courses and meet future challenges. (15-7)

The nursing profession is poised to play a solution role in reducing health care errors. Clinical and organizational expertise allows supply with nourishments to identify systems-related errors and help correct those errors. Simplifying and standardizing processe developing backup rules analyzing organizational design, and performing as a team all are measures that can be taken to improve classification reliability and, therefore, ultimately stop errors and adverse events. (3)

INCIDENT REPORT NOMENCLATURE

The period of time incident report is common in the health care environment. Rather than a piece of paper, this is a proces in which affairs that are inconsistent with routine facility operation or patient care are documented. Incident reports are generated for four images of medical errors: near misses, adverse results intentional unsafe acts, and sentinel adventures These events may affect any human frame on the premises, including patients, employee physicians, visitors, pupils or volunteers. Incident reporting minister tos to