Serious Safety Events

SAFETY EVENT

Serious Safety Event

• Reaches the patient
• Results in moderate to severe harm or death

PRECURSOR SAFETY EVENT

• Reaches the patient
• Results in minimal harm or no detectable harm

Near Miss Safety Event

• Does not reach the patient
• Error is caught by a detection barrier
• or by chance

Frequency of Safety Events

Common Cause Analysis

Top Safety Event Types

Skill-Based Errors

• Performing acts or tasks that require limited or no thought attention

Rule-Based Errors

• Performing acts or tasks that require application of rules
• Accumulated through experience or training
• To familiar situations

Knowledge-Based Errors

• Performing acts or tasks related to new or unfamiliar situations
• Require problem solving and
• For which a rule does not exist or is not known

Human Error Types

Human Error Types

Culture Change

• Fear of punishment of self-reporting of errors
• Fear of punishment of reporting others' errors