Study Conclusion: There was wide variation regarding how clinical programs identify and review adverse events and near misses within the morbidity and mortality conferences, quality assurance meetings, and educational conferences, and some programs had no such processes. A well-designed, coordinated process across all clinical areas that incorporates accepted approaches for event analysis may improve the quality and safety of patient care.

Citation for the Full-text Article

Martinez W, Lehmann LS, Hu Y, Desai SP, Shapiro J. Processes for identifying and reviewing adverse events and near misses at an academic medical center. Joint Commission Journal on Quality and Patient Safety. January 2017; 43(1): 5 -15.

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