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Renamed: Incident Registration System (IRS) > Incident Quality System (IQS)
- Not just reporting, also Prisma analysis and actions to improve quality
Prisma analysis of near-miss:
Continuous Improvement: Methods
Incident Registration
Discussion
To Incident Quality System
Near miss:
Facts prior to
near miss:
Causes:
repair
Almost wrong
treatment administered
Incomplete data
in V&R system
No SOP prior
to start treatment
on correct data
Technologist notices
missing parameter
before start treatment
Parameter
forgotten in
V&R system
Check entry
V&R system
failed
Causes classified in T=technical, HR= human, O=organizational