b'Patient SafetyDiagnostic errorsmisdiagnoses leading to incorrect Nicklaus Childrens Hospital expects that all healthcarechoice of therapy, failure to use an indicated diagnostic providers prioritize patient safety goals and principles,test, misinterpretation of test results, failure to act promote a culture of patient safety, and ensure a safeproperly on abnormal results.healthcare experience for patients, families, and staff.Ways to review a serious safety event include:Root Cause Analysis (RCA): A retrospective, intense The Patient Safety Program supports the hospitalsevaluation of an adverse event or patterns and trends strategic plan to deliver exceptional high-quality care,that vary significantly from standards of practice or remarkable family-centric experiences, and customerwhats expected. service with a focus on transforming our quality andNear Miss Evaluation Processsafety programs. Focuses on improving patient safety andApparent Cause Analysis (ACA): Quality tool that problems in health care safety and how to solve them andevaluates the Apparent Cause or the most prevent harm.fundamental cause identifiable with an investigation Serious Safety Event Identification, Management, andthat is limited in scope and more immediate to an event Reportingoccurring. This may be used for low-risk events, near miss events and/or in conjunction with a Root Cause Analysis. It is NOT a replacement for the more in-depth A serious safety event (SSE) is an unexpected occurrenceanalysis of Root Cause Analysis.involving death or serious physical or psychological injury,Development and implementation of corrective action or the risk thereof. Serious injury specifically includesplansloss of limb or function. The phrase or the risk thereofCHA Patient Safety Organization (PSO)includes any process variation for which a recurrenceCommon Cause Analysis (CCA)would carry a significant chance of a serious adverse outcome. Such events are called serious because theyAfter the systemic analysis of the error or adverse event signal the need for immediate investigation and response.has led to the identification of the cause of the event, a Organizations must complete a root cause analysis (RCA),multidisciplinary team reviews incidents and devises a or in-depth investigation, to determine why the eventcomprehensive plan to ensure the safety of those within occurred. the education and the patients and families that we serve.Types of events reviewed may include:Medication administration errors - wrong medication, wrong dosage, wrong patient, etc.Surgical errors - wrong patient, wrong site, retained instrument, etc.Equipment failuredefibrillator without working batteries, IV pump that results in inadvertent dosing, alarms not working properly, etc.Infection control errorspoor aseptic technique, incorrect processing of sterile instruments and equipment, incorrect isolation practices, lack of standard precautions, etc.Blood transfusion-related errorswrong patient, wrong blood product administered, etc.Figure 1: Patient Safety Program Reporting2024 Survey Readiness Guide 11'