near misses and their importance for improving patient safety.

Near Misses and Their Importance for Improving Patient Safety

Establishing patient safety reporting systems is an important step for improving patient safety. Using such systems, healthcare organizations can collect, analyze, and share information about patient safety (1, 2). A variety of incidents including adverse events, near misses, and medical errors may be considered reportable (2); however, there are some controversies about near misses. Additional...

The JCAHO patient safety event taxonomy: a standardized terminology and classification schema for near misses and adverse events.

BACKGROUND The current US national discussions on patient safety are not based on a common language. This hinders systematic application of data obtained from incident reports, and learning from near misses and adverse events. OBJECTIVE To develop a common terminology and classification schema (taxonomy) for collecting and organizing patient safety data. METHODS The project comprised a syst...

Improving patient safety.

Near-Optimal Padding for Removing Conflict Misses

The effectiveness of the memory hierarchy is critical for the performance of current processors. The performance of the memory hierarchy can be improved by means of program transformations such as padding, which is a code transformation targeted to reduce conflict misses. This paper presents a novel approach to perform near-optimal padding for multi-level caches. It analyzes programs, detecting...

Active Learning with Near Misses

Assume that we are trying to build a visual recognizer for a particular class of objects—chairs, for example—using existing induction methods. Assume the assistance of a human teacher who can label an image of an object as a positive or a negative example. As positive examples, we can obviously use images of real chairs. It is not clear, however, what types of objects we should use as negative ...

Improving patient safety by improving medication communication.

Any time that information about a patient's medication is communicated, there is a potential for error that occurs because of misinterpretation of abbreviations, acronyms, and dose designations. In the following discussion, corrective approaches for reducing the use of error-prone terms will be reviewed. Terms on the "Do Not Use" list are identified and the rationale for using "Tall Man" letter...