Without a Trace(r)… Your Organization May be at Increased Risk for a 'Never Event'

Authors: Kemper, Carol; Boos, Ginn; Moore, Carol

Source: Joint Commission Perspectives on Patient Safety, Volume 9, Number 10, October 2009 , pp. 1-17(17)

Publisher: Joint Commission Resources

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Abstract:

Tracer methodology is an established program evaluation technique that can yield a greater understanding of how processes work day-to-day within an organization. Many institutions have implemented similar internal evaluations to determine survey readiness and to familiarize staff with the technique in preparation for an on-site Joint Commission survey. However, tracers can also be used as a proactive strategy within a hospital's quality and safety program to prevent occurrences that result in patient harm. Since tracers result in a richly detailed assessment of processes, the technique is well suited to uncovering the very latent failures that may otherwise go undetected and could result in the next never event within your facility.

Document Type: Research article

Publication date: 2009-10-01

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The Joint Commission Perspectives on Patient Safety gives readers how to information on analyzing and preventing errors in patient care. While this newsletter emphasizes prevention (a proactive approach), it also addresses the real-world issues of reacting to adverse events.
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