Selection

Selection refers to the process of determining what level of investigation an event receives – routine or expanded. In a healthy organization, many error-based events will be detected. However, not all events should receive the same amount of attention.

The selection process ensures that an organization will target the events with the greatest potential risk, thus making the best use of time and resources.

With effective application of the MERS-TM selection process one can expect that approximately 10% of events will undergo an expanded investigation. Fewer than this will result in less than optimal information available when considering system changes.

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severity

Key attribute to be determined for each reported event. (See ESL and risk).

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Swiss Cheese Model

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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 the following:

• 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.

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violation of safe practices

Violation of safe practices is a disciplinary standard that allows an organization to compare the behavior of its employees against rules and procedures that have been created to maintain safety within the system. A violation of an established safe practice or rule becomes the basis for disciplinary action.

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vulnerability space

The difference in these two points in the work flow indicates a gap referred to as the vulnerability space, which illustrates how long and through how many other work processes (or barriers) the event remained undetected. The amount of vulnerability space has economic implications.

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