Description (See Classification and Description)

List of Terms

Detection

Detection is the first major task or step in the MERS-TM process. Detection involves noticing and recording an event. It is the first step in the MERS-TM event management process.

To achieve the goals of error management, which are risk reduction and process improvement, error detection and reporting rates must increase.

However, an increase in reported events may not equal a higher error rate within the organization. Instead, increased reporting or detection may indicate a greater flow of information into the organization’s event management program.

Information gathered about the detected event is recorded onto the Event Discovery Report form.

List of Terms

detection sensitivity level (DSL)

An organization’s detection sensitivity level or DSL corresponds to the number of events reported. A high detection rate (or high DSL) is preferred because it indicates occurrences can be recorded and monitored, and that potentially dangerous events will not go undetected. Conversely, a low DSL might be considered an indicator of an inadequate error detection and reporting system.

For an organization to manage its errors, the organization must first become aware of their occurrence. Errors that remain undetected over time may yield disastrous results. Thus the goal of error management should be to increase the rate of error detection or reporting.

With respect to DSL, organizations that encourage reporting through confidential, no-fault reporting find that:

• people are more than willing to report
• there is often a ten-fold or greater increase in reporting
• the more positive feedback provided to the staff, the more reporting is encouraged

(See ESL)

List of Terms

error (See active failure or latent condition)

List of Terms

event

An occurrence with a potentially negative outcome that most often results from both latent conditions and human/active error.

List of Terms

event codes

Part of describing an event involves assigning codes that tell:

• what happened and where the event first occurred in the organizational process
• what happened (or what could have happened) and where it was later discovered in the organizational process
  

For example, for the Transfusion Service code PC 002:

• "PC" indicates that the location in the work process was Product Check-in
• "002" indicates that the shipment was incomplete or incorrect.

Transfusion Services and Blood Centers each have their own set of event codes because they perform different functions and processes.

List of Terms

Event Discovery Report

The Event Discovery Report is a form used to record information about the event. Part A of the Event Discovery Report captures information about the discovery of the event. Part B captures information about its occurrence in the system before it was discovered.

List of Terms

event severity level (ESL)

Event severity level or ESL refers to the level of severity assigned to an event. Although an organization's DSL (rate of detection and reporting) should remain high, the ESL or severity level for the events detected should decrease over time as corrective actions are taken.

ESL is one component of risk and is estimated using a Quantified Estimate of Severity (QES).

With the implementation of a confidential, no-fault event reporting system, an organization's DSL will go up and its ESL and risk will go down.

List of Terms

expanded investigation

The goal of event investigation is to gain the knowledge necessary to understand the event. MERS-TM, provides two levels of investigation: routine investigation, which gathers basic information, and expanded investigation, which requires additional time and resources.

The major difference between a routine investigation and an expanded investigation is that an expanded investigation requires a root cause analysis or the building of a causal tree.

The determination of whether or not to conduct an expanded investigation is based upon a number of factors. One major factor is the event’s risk level regarding patient safety, which calls for an expanded investigation if the risk index is .5 or greater. An event may be selected for further investigation in spite of its individual risk index if the presence of many similar events in the database indicate a problem that should be addressed.

An event may also be selected for an expanded investigation based on the unique circumstances within an organization, such as the event presenting a particular risk to the organization’s business goals. In addition, the event may be selected for an expanded investigation based on the expertise and judgment of the QA SysOp and other decision makers.