In healthcare setting, adverse event, error, and near-miss occur frequently. Sometimes, they are unavoidable due to the fact human being can always make mistakes or errors. Let’s give a definition of those three (3) terms. According to World Health Organization; “Adverse event: An injury related to medical management, in contrast to complications of disease (4). Medical management includes all aspects of care, including diagnosis and treatment, failure to diagnose or treat, and the systems and equipment used to deliver care. Adverse event may be preventable or non-preventable.


Error: The failure of a planned action to be completed as intended (i.e. error of execution) or the use of a wrong plan to achieve an aim (i.e. error of planning) (3). Errors may be errors of commission and usually reflect deficiencies in the system of care.
Near-miss or close call: Serious error or mishap that has the potential to cause an adverse event but fails to do so because of chance or because it is intercepted; also called potential adverse event.”
There are many examples of adverse events. Those include but not limited to the transmission of an infectious agent to a patient during an injection; administrating incorrect medication or dosage; catheter-acquired infections. Many of those adverse events are preventable. Examples of medical errors are multiple: they include medication or dosage errors; wrong procedure on the wrong patient.
About Medical errors; John Bonifield and Elizabeth Cohen (CNN 2012) have reported: “’Mistakes are happening every day in every hospital in the country that we’re just not catching,’ says Dr Albert Wu, an internist at johns Hopkins Hospital. Medical errors kill more than a quarter people every year in the United States and injure millions. Add them all up and ‘you have probably the third leading cause of death’ in the country, says Dr. Peter Pronovost, an anesthesiologist and critical care physician at Johns Hopkins Hospital. The harm is often avoidable, and there are strategies you can use to help doctors and nurses get things right.”
A clinical leader should positively address those situations. He or she should improve the internal communication; he or she should focus on educating the staff members. The training program would include the different methods that are taught to avoid preventable adverse events and preventable medical errors. A clinical leader should also address the situations knowing that errors are inherent in human nature. But, everything should be done to avoid the maximum of errors in healthcare setting. A clinical leader would identify the nature and the cause of errors and he or she would encourage reporting them. The process of reporting medical errors should be simplified by a clinical leader. That approach would encourage staff members to easily and honestly report their errors or mistakes. We have to remember that Human are fallible; we make mistakes. Therefore; to better address those three situations (adverse events, medical errors, near miss), a clinical leader should always take into account the human fallibility and the imperfections of the healthcare system in general.
FOOD FOR ALL (FFA) – FEED FOR HOPE
Mohamed Elmahady CAMARA
References:
Bonifield J. and Cohen E., (CNN 2012): 10 shocking medical mistakes; retrieved from
http://www.cnn.com/2012/06/09/health/medical-mistakes/
World Health Organization: World Alliance for Patient Safety: WHO draft guidelines for adverse event
reporting and learning systems: From information to action: Definition; retrieved from
http://www.who.int/patientsafety/events/05/Reporting_Guidelines.pdf

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