Patient Safety Plan Development Considerations

Purpose—Patient safety plans must direct actions to improve healthcare safety and reduce risk to patients through a culture that encourages 

Adverse Events— Adverse events are untoward incidents, therapeutic misadventures, iatrogenic injuries, or other adverse occurrences directly associated with care or services provided. Adverse events may result from acts of commission or omission. Adverse events can include patient falls, medication errors, procedural errors or complications, suicides, and missing patients. An adverse event can also be categorized as either a sentinel event or near miss. 

Sentinel Event— A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase or the risk thereof includes any process variation for which a recurrence would carry a significant chance of serious adverse outcome. 

Near Misses— 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. Near misses are opportunities 

Patient rights and assessment Patient and continuum of care Patient/family education 

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Appendix Y Patient Safety Plan Development Considerations... 

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