Читать книгу Kelly Vana's Nursing Leadership and Management - Группа авторов - Страница 205

An error may cause varying levels of harm to a patient. A near miss safety event occurs when the safety event doesn't reach the patient because it is caught by chance or because the process was engineered with a detection barrier. For example, Ms. Johnston and Ms. Johnsen may both be hospitalized on the same nursing unit. The nurse may accidently bring Ms. Johnston's medications to Ms. Johnsen. By properly identifying the patient using two unique identifiers, this error can be identified before causing harm to the patient. Nurses often fail to report Near Misses, rationalizing that no one was hurt. However, near miss safety events serve as an early warning system of something that could go wrong. By reporting near miss safety events, health care organizations can work on improving processes so that no one else makes the same error.