A quality improvement program

By publishing To err is human: building a safer healthcare system in 2000, the Institute of Medicine made healthcare leadership, legislation, and consumers aware of the issues affecting patient safety. The report stated that medical errors were not uncommon and were costly to both the patient and the healthcare organization. Medical errors were usually caused by complex healthcare systems and led to the death of some patients. Following the publication of this report, a new trend was seen in research devoted to patient safety. Healthcare organizations started to focus quality improvement programs on improving patient safety by reviewing complex healthcare processes. Research focused on the prevalence of pediatric medical errors and identified reasons for the increased vulnerability of pediatric patients to these adverse medical events. A large Midwestern healthcare organization in the USA already had a developed quality improvement program for event-reporting in place. The organization's event reporting system has continue to evolve due to legislative changes such as the 2003 Minnesota law requiring hospitals, community behavioral health hospitals, and outpatient surgical centers to report the occurrence of any of the 28 ‘never’ events. One individualized unit in this large Midwestern healthcare organization will share its quality initiatives, documentation improvement initiatives, near-miss and event-reporting program, and promotion for patient and family involvement in the daily care plan. This article will identify the importance of developing a non-punitive, transparent and voluntary reporting system to continue to meet the ongoing patient care safety needs.