Life-Saving Errors: Health 2.0 Incident Reporting |
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| Event | Interactive 2011 |
| Format | Panel |
| Organizer | Dennis Grace – Medical BillDog |
| Description | On March 28, 1979 the Three-Mile Island-Unit 2 nuclear power plant experienced a feed system failure that ultimately resulted in the largest release of radioactive material to the atmosphere of any nuclear incident in the United States. The Three-Mile Island incident could easily have been prevented. Three months earlier a similar incident occurred in another plant at low power. Plant supervisors reported the first incident to the NRC—even going so far as to note the possible disastrous consequences of such an incident at power—but the TMI-2 operators were not aware of the earlier incident. The NRC initiated a simple incident reporting system. Today, errors that result in plant damage and near misses are collected and published to operators across the country. Recently the Institute for Healthcare Improvement has been encouraging medical personnel to share their mistakes with their peers in the hopes that their errors, too, might prevent disaster. The IHI program is a good one, but I think it could be much better. My proposal is twofold. First, let’s establish a national medical incident reporting system. Every iatrogenic infection, injury, or death reported could result in untold lives saved. Second, for greatest efficiency, immediacy, and impact, this incident reporting system should take the form of a medical error Wiki, supported by alerts through social media such as LinkedIn and Twitter. |
| Questions Answered |
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| Level | Advanced |
| Category | Health |
| Tags | Error, Incident, Medicine |