First few Article Sentences
Each year in the United States, there are many adverse events reported in healthcare facilities. An adverse event is defined as “an injury that was caused by medical management rather than the patient’s underlying disease;” also sometimes called “harm,” “injury,” or “complication.” An adverse event may or may not result from an error. Successful management of an adverse event requires an institutional framework supported by a culture of safety and quality. Providing a structured root cause analysis plan should be the focus of every hospital investigation.
Investigating near misses has key advantages. A near miss is a serious error or mishap that has the potential to cause an adverse event but fails to do so by chance or because it is intercepted. There is no risk of blame or litigation to investigate near misses. When a hospital is serious about learning from all potential errors, near misses provide recommendations for positive change.