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Patient Safety Back to Course Index


Patient safety is the absence of preventable harm to a patient during the process of health care and reduction of risk of unnecessary harm associated with health care to an acceptable minimum.  An acceptable minimum refers to the collective notions of given current knowledge, resources available and the context in which care was delivered weighted against the risk of non-treatment or other treatment.    

An effective organizational safety program cannot exist without optimal reporting of medical errors and occurrences. Therefore, a non-punitive approach in the management of errors and occurrences is recommended to improve patient safety.



A sentinel event is defined by American healthcare accreditation organization The Joint Commission (TJC) as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient’s illness. This includes, but is not limited to death, suicide during or within 72 hours of discharge, rape, abduction of a patient, permanent loss of function due to a facility acquired infection, and elopement with death or loss of function.



Incident reporting is the process of documenting all injuries, near misses and accidents. An incident report should be completed at the time an incident occurs no matter how minor an injury is.

Incident reporting is frequently used as a general term for all voluntary patient safety event reporting systems, which rely on those involved in events to provide detailed information. Initial reports often come from the front line personnel directly involved in an event or the actions leading up to it rather than management or patient safety professionals. They are a mainstay of efforts to detect patient safety events and quality problems. 

Key components of an effective reporting system:

  • Institution must have a supportive environment for event reporting that protects the privacy of staff who report occurrences.
  • Reports should be received from a broad range of personnel.
  • Summaries of reported events must be disseminated in a timely fashion.
  • A structured mechanism must be in place for reviewing reports and developing action plans.



Any unusual event that occurs involving a patient, staff member, or visitor that transpires in or on the premises of the facility.  This includes but is not limited to any type of an altercation verbally or physically with either a staff member and/or patient, staff or patient abuse or neglect towards another patient or staff member, psychiatric emergency, any type of self-destructive behavior by a patient, medication error, slip and/or fall, alcohol or drug use by a patient or staff, contraband found in a patient’s room or on their person, weapon, pharmacy error, procedure break, patient or staff injury, medical problem, emergency call for 911, vehicle accident, property damage, patient or staff cut or injury, trespassing, and any type of violent action and/or threat to an employee or patient.



Adverse events are untoward incidents, therapeutic misadventures, injuries or other adverse occurrences directly associated with care or services provided. Adverse events may result from acts of commission or omission (i.e.: administration of the wrong medication, failure to make a timely diagnosis or institute the appropriate therapeutic intervention, etc.). Some examples of adverse events include falls, medication errors, procedural errors/complications, suicide/homicide attempt or gesture, alleged abuse, AMA, etc.



A Near Miss is an event or situation that could have resulted in an accident, injury or illness, but did not, either by chance or through timely intervention. An example of a Near Miss would be: A procedure almost performed on the wrong patient due to lapses in verification of patient identification but were caught at the last minute by chance. Near Misses are opportunities for learning and afford the chance to develop preventive strategies and actions. Near Misses will receive the same level of scrutiny as adverse events that result in actual injury or negative outcome.



An unanticipated outcome is defined as a negative or unexpected result stemming from a diagnostic test, medical judgment or treatment, surgical intervention or from the failure to perform a test, treatment or intervention. The unanticipated outcome may or may not be the result of error or negligence.



Intentional unsafe acts, as they pertain to patients, are any events that result from: a criminal act; a purposefully unsafe act’ an act related to alcohol or substance abuse, impaired provider/staff; or events involving alleged or suspected patient abuse of any kind.



Root cause analysis (RCA) is defined as a collective term that describes a wide range of approaches, tools, and techniques used to uncover causes of problems. The highest-level cause of a problem is called the root cause.  It is the core issue that sets in motion the entire cause-and-effect reaction that ultimately leads to the problem(s).

There are many methodologies, approaches, and techniques for conducting root cause analysis. Here are five examples:

  1. Events and causal factor analysis: Widely used for major, single-event problems, such as a refinery explosion, this process uses evidence gathered quickly and methodically to establish a timeline for the activities leading up to the accident. Once the timeline has been established, the causal and contributing factors can be identified.
  2. Change analysis: This approach is applicable to situations where a system’s performance has shifted significantly. It explores changes made in people, equipment, information, and more that may have contributed to the change in performance.
  3. Barrier analysis: This technique focuses on what controls are in place in the process to either prevent or detect a problem, and which might have failed.
  4. Management oversight and risk tree analysis: One aspect of this approach is the use of a tree diagram to look at what occurred and why it might have occurred.
  5. Kepner-Tregoe Problem Solving and Decision Making: This model provides four distinct phases for resolving problems:
    1. Situation analysis
    2. Problem analysis
    3. Solution analysis
    4. Potential problem analysis



Upon entry into the system, each patient and legal guardian (if appropriate) should be informed verbally and in writing of their rights. Each individual should sign and be given a copy.   Patient Rights should be posted in visible areas of all treatment sites.



Confidentiality is one of the most basic rights that patients have.

No information pertaining to the patient should be given to anyone without proper authorization



Neglect or abuse should not be tolerated. Any incident of suspected abuse should be immediately reported.

Neglect is defined as the withholding of treatment necessary for the patient and to support their individual dignity.

Abuse is the application of anything that is destructive to the patient, their treatment, their dignity and the therapeutic relationship. It can be physical, verbal, or psychological.



All staff should display ethical behavior at all times. Examples of unethical behavior include:

  • Giving a patient your home phone number.
  • Meeting a patient or an ex-patient at a self-help group meeting.
  • Any type of a relationship with a patient or an ex-patient.
  • Phoning a patient or an ex-patient.
  • Having any type of contact by phone or in person with a patient who has completed treatment at the facility at any time.
  • Accepting a gift of any kind from a patient.
  • Inviting a patient or an ex-patient to a party at your house.
  • Telling a patient your personnel problems or your personnel history regarding any type of personnel nature (marriage, relationships, or any type of an issue of a sensitive nature)
  • Touching a patient inappropriately
  • Telling a patient or an ex-patient that you are attracted to them.
  • Any type of breach of confidentiality.

If you are unsure of an unethical situation, please contact your supervisor.



Anyone driving clients or patients should adhere to safety guidelines.  Here are examples of rules to follow:

Before loading passengers:

  • The vehicle is parked in a safe parking spot away from traffic.
  • The vehicle is in good operating condition. Do a walk through each time before driving.
  • The gas tank is at least ¼ full.
  • The vehicle is in park, emergency brake is on, radio is off and air conditioning or heat is on (as appropriate).
  • Complete a vehicle checklist each day.


While loading passengers:

  • No food, drinks or smoking allowing on board.
  • Each person on the bus is assigned and accounted for on a seat.
  • Every patient puts on a seatbelt before vehicle is in motion.


While Driving:

  • Slow and careful always.
  • All passengers must be seated at all time while the vehicle is moving.
  • Seatbelts must be worn by drivers and passengers.
  • All passengers should remain seated, talk in low tones, keep all hands and body parts in the vehicle and are expected to behavior appropriately.
  • In the event these rules are broken, the driver reserves the right to safely pull the vehicle over until it is safe to drive again.


While unloading passengers:

  • The vehicle is parked in a safe parking spot away from traffic.
  • The vehicle is in park, emergency brake on, radio off and air conditioning or heat is on.

2019 Behavioral Health Care National Patient Safety Goals     

The purposed of the National Patient Safety Goals is to improve patient safety.  The goals focus on problems in health care safety and how to solve them.

Improve the accuracy of the identification of individuals served.

  1. Use at least two identifiers of the individual served when administering medications or collecting specimens for clinical testing. The room number or physical location of the individual served is not used as an identifier.
  2. Label containers used for specimens in the presence of the individual served.


Improve the safety of using medications.

  1. Obtain and/or update information on the medications the individual served is currently taking. This information is documented in a list or other format that is useful to those who manage medications. Note 1: The organization obtains the individual’s medication information during the first contact. The information is updated when the individual’s medications change.
    Note 2: Current medications include those taken at scheduled times and those taken on an as-needed basis. See the Glossary for a definition of medications.
    Note 3: It is often difficult to obtain complete information on current medications from the individual served. A good faith effort to obtain this information from the individual and/or other sources will be considered as meeting the intent of the EP.
  2. Define the types of medication information (for example, name, dose, route, frequency, purpose) to be collected in non-24-hour settings based on situations of individuals served and characteristics of different settings.
  3. For organizations that prescribe medications: Compare the medication information the individual served brought to the organization with the medications ordered for the individual by the organization in order to identify and resolve discrepancies. Note: Discrepancies include omissions, duplications, contraindications, unclear information, and changes. A qualified staff member, identified by the organization, does the comparison.
  4. For organizations that prescribe medications: Provide the individual served (or family as needed) with written information on the medications the individual should be taking at the end of the encounter (for example, name, dose, route, frequency, purpose). Note: When the only additional medications prescribed are for a short duration, the medication information the organization provides includes only those medications.
  5. For organizations that prescribe medications: Explain the importance of managing medication information to the individual served. Note: Examples include instructing the individual served to give a list to his or her primary care physician; to update the information when medications are discontinued, doses are changed, or new medications (including over-the-counter products) are added; and to carry medication information at all times in the event of emergency situations.


Reduce the risk of health care–associated infections

  1. Implement a program that follows categories IA, IB, and IC of either the current Centers for Disease Control and Prevention (CDC) or the current World Health Organization (WHO) hand hygiene guidelines. (See also IC.01.04.01, EP 1) Note: This element of performance applies only to organizations that provide physical care.
  2. Set goals for improving compliance with hand hygiene guidelines. (See also IC.03.01.01, EP 1) Note: This element of performance applies only to organizations that provide physical care.
  3. Improve compliance with hand hygiene guidelines based on established goals. Note: This element of performance applies only to organizations that provide physical care. 


The organization identifies safety risks inherent in the population of the individuals it serves.

  1. Conduct a risk assessment that identifies specific characteristics of the individual served and environmental features that may increase or decrease the risk for suicide.
  2. Address the immediate safety needs and most appropriate setting for treatment of the individual served.
  3. When an individual at risk for suicide leaves the care of the organization, provide suicide prevention information (such as a crisis hotline) to the individual and his or her family.


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