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Adverse Event Prevention and Management 

Adverse Event Prevention and Management
Adverse Event Prevention and Management

Patrick J. Guffey

and Martin Culwick

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date: 30 November 2020

Adverse events are an unfortunate reality of caring for patients in our current healthcare system. Preventing and mitigating these events are an important part of quality improvement. First, an understanding of what events occur and how often they are occurring is critical to planning improvements. Incident reporting systems are one way of gathering this information. Then, events should be categorized and analyzed for improvement. The failure mode and effects analysis (FMEA) and bow-tie diagram are two tools for this purpose. Once an event has occurred, consideration should be given to the caregivers as well as the patient when managing and resolving adverse events. Prevention requires strong analysis of events and recognition of both latent (system) and human causes. Interventions have different degrees of effectiveness, ranging from highly effective forcing functions, to marginally effective encouraging statements. There are four steps to event management: mitigation, immediate management, refractory management, and follow-up.

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