Adverse event reporting.pdf

the outcome. For example, regression analysis can be used to investigate whether
patient diagnosis is a predictive factor for dosing error. The major use for this analytical
approach is to go beyond identifying relationships to hypothesis testing.
The sentinel event alerts issued by JCAHO include risk reduction strategies based
on causal analyses submitted with reports, such as finding that medication errors
attributable to illegible handwriting or poor communication are more common
when abbreviations are used. Eliminating abbreviations has thus become one of the
JCAHO patient safety goals for hospital accreditation.
Systems analysis
The ultimate aim of reporting is to lead to systems improvements by understanding
the systems failures that caused the error or injury. At the organizational level, this
requires investigation and interviews with involved parties to elicit the contributing
factors and underlying design failures. A national reporting system must receive this
level of information in order to identify common and recurring systems failures. For
example, if analysts repeatedly find similar underlying systems defects in reports
of a specific type of error, then remedial actions should focus on correction of that
failure.
The Australian Patient Safety Foundation identified problems with valve-controlled
flow and pressure occurring with anaesthetic machines. Query of the database
provided a deconstruction of the malfunction types and suggested, among other
things, that frequent maintenance and audible alarms on pressure relief valves could
prevent these mishaps (18).