This meeting was beneficial to me as nurse due to the increased understanding

This meeting was beneficial to me as nurse due to the

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This meeting was beneficial to me as nurse due to the increased understanding of continuous process improvement and how the ratings such as SSE (serious safety events) 1-5 are determined. Exposure to this type meeting changes the way I view or evaluate any situation occurring in my local unit.ProblemThe meeting I attended had 8 cases for review:Wrong site procedure (1)Delay of care (1)Medication Error (2)Patient falls (4)The Filter Committee reviewed the fact in each case and heard from any leadership in attendance. In each case, an algorithm was applied through a series of questions to
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determine if the case was a Serious Safety Event (1-5), a Potential Safety Event (1-5) or aGood Catch.Solution1. Wrong site procedure: scored as PSE1, gaps in practice were identified. Unit director to review/update policy and provide staff education.2. Delay of care: scored as Near Miss. No process gaps identified. Variance will be reviewed by physician peer review.
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  • Winter '16
  • Nursing, Health care provider

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