human error (See active failures)

List of Terms

IOM Report (See To Err is Human)

One of the most influential forces driving public policy on error management is a report from the Institute of Medicine (IOM) entitled "To Err is Human."

The report focuses on the prevalence and dangers of error in the public health system and makes recommendations for creating a safer system. Recommendations include improved data collection and analysis and the implementation of effective event reporting systems.

Recommendations from IOM Report include:

• Establish a national focus of research, tools, and protocols to enhance knowledge base about patient safety.
• Identify and learn from errors through both mandatory and voluntary reporting systems.
• Raise standards and expectations for improvement in safety through actions of oversight organizations.
• Create safety systems inside health care organizations through implementation of safe practices at the delivery level.

List of Terms

iceberg model of events

The iceberg model presents a metaphor for how events are perceived. In the model, misadventures are represented by the part of the iceberg that is visible above water, commonly known to be the smallest part of the iceberg. No harm events are represented in a section of iceberg immediately below the water line. Near miss events are represented as the largest part of the iceberg most thoroughly hidden from view in deeper water.

The iceberg model shows that although misadventures are most often the focus, near miss and no harm events, though hidden, are actually more numerous and provide a greater opportunity for learning and process improvement.

List of Terms

Interpretation

The real value of MERS-TM is that it allows managers and supervisors to dynamically interpret data and target the areas posing the greatest risk based on aggregate data rather than an individual event.

Interpretation provides various methods for looking at data from a broad perspective to help organizations avoid the all too common temptation to enact quick fixes based on a single event.

List of Terms

Investigation (See routine investigation and expanded investigation)

The goal of the Investigation step is to gain the knowledge necessary to fully understand the event. In MERS-TM, there are two levels of investigation:

• Routine investigation – gathers the basic information
• Expanded investigation – requires additional time and resources

As part of the event management process, all events receive at least a routine investigation; however, some events (approximately 10%) should receive an expanded investigation. The major difference between a routine investigation and an expanded investigation is that an expanded investigation requires a root cause analysis.

The risk index is the primary criterion used to determine whether an expanded investigation is necessary.

List of Terms

Just culture