BOP Program Statement 6013.01 § 10

PROGRAM. Each HSU will develop a plan to identify risks, and

minimize medical errors. When incidents or errors occur, the HSA

will conduct a coordinated review to:

! identify causes;

! prevent repetition; and

! minimize the financial impact of any litigation.

Both concurrent and retrospective review systems must be used

when conducting risk/error management.

An error is the failure of a planned action to be completed as

intended, or the use of the wrong plan or treatment to achieve

the intended health care outcome.

a. The objectives of the Risk Management/Error Program are to:

(1) Measure the frequency and severity of identified

problems/hazards/errors;

(2) Minimize or eliminate risk factors;

(3) Decrease the frequency and severity of preventable

errors that may result in adverse outcomes, or injuries

to patients, staff, and visitors;

(4) Develop and implement methods to eliminate preventable

dangers;

(5) Develop and implement appropriate educational and

training programs; and

(6) Maintain current data related to health care errors.

b. The Health Services Division will provide information

and periodic reports to institutions on risk management issues

and errors that occur in the Bureau that may be pertinent to

health care operations at all Bureau institutions.