A hospital has significantly reduced the number of errors and near-miss episodes it has in the past 2 years. An accreditation body visitor might conclude that error and near-miss reductions are most directly related to
a. remediation of individual employees who make errors.
b. policies and procedures that have been created to avoid problems.
c. facility strategies to detect and address any potential problems.
d. staff education in facility patient safety processes.
C
Facilities that operate under a culture of safety encourage all employees to be vigilant in observing for conditions and processes that could potentially lead to errors and near misses.
Individuals who make errors may indeed be given additional education or training, but this is not the best answer because most errors come from system problems.
Facilities should have policies and procedures to help lessen the number of errors or near misses, but without vigilance in finding sources of potential problems, the policies created may not be maximally beneficial.
Educating the staff does not go far enough in preventing errors. The facility needs to make a concerted effort to detect and address potential system problems, as system problems are the most common cause of errors.
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