Discussion Question 2:

In order to identify and report elements that define an adverse event, medical error and near miss, it is important that the nurse have adequate understanding of patient safety and how it has transitioned from being risk management. However, for the nurse to have understanding of what errors are and how to mitigate them, he or she must promote a system to prevent errors that is patient centered. Having a proper understanding of how errors happen can minimize risk but also set a better course for patient quality care centered on his or her needs. The nurse must have adequate understanding of process management, chain of command and knowledge management. The Institute of Medicine or IOM published a report called Crossing the Quality Chasm (2001) which outlines patient centered quality care. It involves understanding how routine and deviating from automatic processes could cause errors and increase risk. James Reason suggests sometimes this happens because of outside events but other times events happen on the inside of healthcare that he believes can be better controlled. The IOM suggests patient care can be controlled if they are center to the process. Knowledge of healthcare strategies, open communication and partnership between patients, his or her families and healthcare professionals should be the design for minimizing errors. The IOM’s (2001) report suggests safety begins with continuous, customized and controlled care for the patient as this also reflects the values that go into defining healthcare process management. Knowledge and experience for deeper comprehension of errors and filtering out processes that work and do not work will help healthcare professionals remain focused on patient needs. This mirrors strategy because to pick a part every segment, every strain of the process and compare with error, the variable that changed