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Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning system.

Authors
  • Ford, Eric C
  • Smith, Koren
  • Harris, Kendra
  • Terezakis, Stephanie
Type
Published Article
Journal
Medical Physics
Publisher
Wiley (John Wiley & Sons)
Publication Date
Nov 01, 2012
Volume
39
Issue
11
Pages
6968–6971
Identifiers
DOI: 10.1118/1.4760774
PMID: 23127090
Source
Medline
License
Unknown

Abstract

In these examples, a policy was adopted based on incident learning, which prevented several errors, at least one of which was potentially severe. These examples underscore the need for a rigorous, systematic incident learning process within each clinic. The experiences reported in this technical note demonstrate the value of near-miss incident reporting to improve patient safety.

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