Reporting near-miss events in nursing homes.
Since the Institute of Medicine report To Err Is Human was published in 1999, improving patient safety has become a major initiative for nurses working in all care settings. Nursing homes are a fertile environment for both a high frequency of adverse events to occur and a high number of institutional barriers to reporting them. This article outlines the barriers to reporting adverse events in nursing homes and provides support for why reporting near-miss events can serve as a means of reducing these barriers. It also provides recommendations and specific strategies for how to implement near-miss reporting systems in nursing homes such as policy changes, supportive leadership, and educating nurses about near-miss events. Further nursing research in this evolving area of patient safety is warranted.
Wagner
Laura M
LM
Baycrest Centre of Geriatric Care, Kunin-Lunenfeld Applied Research Unit, Toronto, ON, Canada. lwagner@klaru-baycrest.on.ca
Capezuti
Elizabeth
E
Ouslander
Joseph G
JG
D006801:Humans; D007318:Inservice Training; D007857:Leadership; D019300:Medical Errors / Q000517:prevention & control*; D009735:Nursing Homes / Q000592:standards*; D016134:Organizational Policy; D016730:Program Development; D012308:Risk Management / Q000458:organization & administration*; D014481:United States