![]() |
![]() |
|||||||
![]() |
||||||||
![]() |
Description (See Classification and Description)
DetectionDetection 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.
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:
(See ESL)
error (See active failure or latent condition)
eventAn occurrence with a potentially negative outcome that most often results from both latent conditions and human/active error.
event codesPart of describing an event involves assigning codes that tell:
For example, for the Transfusion Service code PC 002:
Transfusion Services and Blood Centers each have their own set of event codes because they perform different functions and processes.
Event Discovery ReportThe 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.
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.
expanded investigationThe 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. List of Terms |
|||||||
About MERS-TM | Training | Support/Materials | Database Functions | Articles/Links | How Do I Start? | Glossary Site Index | Security/Privacy Policy | | Home
|