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Reporting Committee Summaries

Educational Resources

Reporting Committee Summaries

The NCPS Reporting Committee is comprised of nurse, pharmacist, physical therapy and physician members. The committee meets on a quarterly basis to review selected, de-identified, reported events, discuss the identified causal factors and the overall thoroughness of the information reported, and identify risk mitigation strategies.

The Reporting Committee Summaries provide a comprehensive overview of several of the safety events that were discussed, and are developed within the framework of an organizational self-assessment tool which asks, "Could this happen in your organization?" This framework, and the inclusion of links to best practice recommendations and other patient safety-related resources enables our members to proactively identify risk and develop mitigation strategies to prevent the events from occurring in their healthcare setting. 

The list below displays the topics that have been included in reporting committee summaries that are available to our members. 

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  • The Q1 2018 summary provides an organizational self-assessment of risk mitigation strategies focused on retained gauze, obstetrical emergencies, high alert medications, medication reconciliation, tourniquet usage, care of minors, outpatient falls, and wrong site surgery.

  • The Q2 2018 summary provides an organizational self-assessment of risk mitigation strategies focused on fall prevention with cognitively impaired patients, retained foreign objects, medication errors with pediatric chemotherapy infusion, EHR downtime procedures, barcode scanning work arounds, safe patient handling, patient handoff, delays in rapid response, sepsis and delirium in older adults, and supporting second victims and compassion fatigue.

  • The Q3 2018 summary provides an organizational self-assessment of risk mitigation strategies focused on OR safety including fire hazards, wrong site surgery, and patient identification, obtaining pediatric medical history, pediatric dosing conversion and abbreviations, fall risk assessment and prevention, and managing airway emergencies.

  • The Q4 2018 summary provides an organizational self-assessment of risk mitigation strategies focused on patient falls, medication errors, OR safety, obstetrical events, and at-risk behavior in staff members.

  • The Q1 2019 summary provides an organizational self-assessment of risk mitigation strategies focused on human factors and system design as they relate to medication and diagnostic errors.

  • The Q4 2019 summary provides an organizational self-assessment of risk mitigation strategies focused on fall risk reduction in the emergency department, on a medical/surgical unit, and in the OR.

  • The Q1 2020 summary provides an organizational self-assessment of risk mitigation strategies focused on obtaining accurate allergy history, and medication errors related to infusion rate and communication failures.

  • The Q2 2020 summary provides an organizational self-assessment of risk mitigation strategies focused on specimen handling, and test resulting.

  • The Q3 2020 summary provides an organizational self-assessment of risk mitigation strategies focused on patient education; highlighting the importance of Teach Back and other strategies aimed at promoting health literacy.

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