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A never event is the "kind of mistake (medical error) that should never happen" in the field of medical treatment. [1] According to the Leapfrog Group never events are defined as "adverse events that are serious, largely preventable, and of concern to both the public and health care providers for the purpose of public accountability." [2]
The National Patient Safety Agency encourages voluntary reporting of health care errors but has several specific instances, known as "Confidential Enquiries", for which investigation is routinely initiated: maternal or infant deaths, childhood deaths to age 16, deaths in persons with mental illness, and perioperative and unexpected medical ...
Applications include aviation safety, engineering, healthcare, emergency service organizations, and as the principle behind layered security, as used in computer security and defense in depth. Although the Swiss cheese model is respected and considered a useful method of relating concepts, it has been subject to criticism that it is used too ...
The California Department of Public Health found that Adventist Health Simi Valley, seen here on Sept. 22, "failed to ensure that patients had been protected from medication errors."
Variations in healthcare provider training & experience [45] [52] and failure to acknowledge the prevalence and seriousness of medical errors also increase the risk. [53] [54] The so-called July effect occurs when new residents arrive at teaching hospitals, causing an increase in medication errors according to a study of data from 1979 to 2006.
The report called for a comprehensive effort by health care providers, government, consumers, and others. Claiming knowledge of how to prevent these errors already existed, it set a minimum goal of 50 percent reduction in errors over the next five years. Though not currently quantified, as of 2007 this ambitious goal has yet to be met.
The doctors and nurses didn’t believe Tomisa Starr was having trouble breathing. Two years ago, Starr, 61, of Sacramento, California, was in the hospital for a spike in her blood pressure.
By gathering data about errors made, then collating, grouping and analyzing them, it can be determined whether a disproportionate amount of similar errors are being made. If this is the case, a contributing factor may be disharmony between the respective systems/routines and human nature or propensities .