[Failure prevention in clinical practice through identification of failure examples].
"Learning from ones mistakes" is an essential part of clinical quality improvement. But focusing on a retrospective analysis of mishaps from the past is not sufficient for quality enhancements, nor is the restriction to mistakes in the solely legal sense. Analysis has to include anonymous data aggregated over dissatisfying results from multiple sources. Recognizing patterns of underlying causes for errors is the key to effective error prevention. In many cases the true cause might be predominantly organizational.
Hansis
M L
ML
RHON-KLINIKUM AG, Bad Neustadt. m.hansis.qm@rhoen-klinikum-ag.com
D019221:Mandatory Reporting; D019300:Medical Errors / Q000517:prevention & control*; D010818:Practice Patterns, Physicians' / Q000458:organization & administration*; D011785:Quality Assurance, Health Care / Q000379:methods / Q000458:organization & administration*; D012308:Risk Management / Q000379:methods / Q000458:organization & administration*; D017751:Safety Management / Q000379:methods*; D013597:Systems Analysis