Hi Keri!
event reporting and correcting errors is always more effective when addressed in a non-punitive, cause-solution approach. Using punitive measures usually makes people less likely to report an error because they're afraid of being punished. Of course, gross negligence needs to be addressed properly, but in most cases a root-cause analysis is the best approach. In our clinic when we have an error, the person who made the error fills out a SERS report, they get assistance from management/leadership if needed on completing the form, following up with a clinician to investigate if there is a risk of harm or actual harm, and informing the patient. Once that portion is completed, the staff member and leadership discuss the error, how it happened, and work together to come up with solutions to prevent themselves or others from making a similar error in the future. Without naming/blaming, we review errors in our huddles and things to be mindful of. Using a systems and solutions oriented approach has resulted in low error rates and creative solutions for our team, and often solutions that end up being adopted by other clinics or departments based on that success. I can't remember who exactly came up with this approach, but I know many healthcare organizations have adopted it (I think it originally came from a manufacturing company, airplanes?). Best of luck!
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Heather Perkins BSN, RN, ANB-BC
Kaiser Permanente Northwest
Vancouver WA
(360) 241-1178
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