This meeting was beneficial to me as nurse due to the

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.
Problem
The 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

determine if the case was a Serious Safety Event (1-5), a Potential Safety Event (1-5) or a
Good Catch.
Solution
1. 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.