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Quality improvement


Learning from adverse events (accidents in Québec)

Learning from near misses


  • Near misses are opportunities to prevent harm to patients in the future.
Near miss with two airplanes

A near miss in aviation refers to 2 aircraft in flight narrowly missing a collision with each other.

A near miss in medicine is an event that might have resulted in harm but the problem did not reach the patient because of timely intervention by healthcare providers or the patient or family, or due to good fortune. Near misses may also be referred to as "close calls" or "good catches."

In a culture of safety, near misses are "free lessons."  [REF]
Reason, James. The Value of Close Calls in Improving Patient Safety: Learning How to Avoid and Mitigate Patient Harm, edited by Albert Wu. Joint Commission Resources, 2011.

Near misses may occur many times before an actual harmful incident. Many avoidable deaths have a history of related near misses preceding them.  [REF]

Institute of Medicine. Patient Safety: Achieving a New Standard of Care. Washington, DC. National Academies Press, 2004.

"High reliability organizations" view near misses as learning and improvement opportunities. Such organizations ask: "How will the next patient be put at risk or harmed?", they value and acknowledge input, and make appropriate improvements.

Conversely, "low reliability organizations" are falsely reassured because no harm occurs and they mistakenly conclude the system of care is safe. They wait for harm to occur.

System failures
System failure:  The lack, malfunction or failure of policies, operational processes, or the supporting infrastructure for the provision of health care.
 or provider performance issues including provider error
Error - provider (medical) error:  An act (plan, decision, choice, action or inaction) that, given the information available and the patient's clinical condition at the time, was done wrongly or performed incorrectly in those circumstances, and therefore resulted in an adverse event or near miss.

The use of the term "error" should generally be avoided, especially before all the facts are known, because it can inappropriately suggest there was blameworthy conduct on the part of the health care provider. The term may be misunderstood to mean the care provided was substandard or negligent in law. Errors may or may not be the result of negligence.

Error in judgment:
A reasonable decision or choice, made carefully at the time, but in retrospect might not be considered by some as the best choice or decision. Physicians are not necessarily in breach of their duty toward a patient simply because they have committed an error of judgment after a careful examination and thoughtful analysis of a patient's condition. Errors in judgment may occur, for example, in diagnosing a condition or in choosing among different therapeutic approaches.

, or both, may lead to a near miss.

Why are near misses important?

  • They represent "error prone situations" and "error traps" waiting to catch other patients and providers.
  • There is less anxiety about blame as there are no liability concerns (because no one has been harmed).

Why should near misses be reported?

Many hospitals have near miss reporting systems. Offices and clinics should encourage staff to report near misses.

Reporting near misses helps to:

  • reduce risks for all patients by not waiting for harm to occur
  • trigger improvements in weak spots in the processes of care
  • alert other providers to possible vulnerabilities and gaps in training
  • contribute to planning, recovery testing, and harm mitigation strategies following  events that do result in harm

Female nurse at bedside of female patient

Examples of near misses

Sometimes a medication is prescribed without considering the patient's allergies or potential for significant drug interactions. In many, but not all, situations the patient or pharmacist recognizes the risk in time.

Here are some other examples of near misses.

Case: Near miss prior to surgery
Halted surgery scene

Background

Mrs. G is scheduled for important surgery. She takes warfarin for treatment of atrial fibrillation.

It is discovered in the operating room that Mrs. G. had not stopped her warfarin as instructed.

The surgery is postponed.

Lessons learned

If this near miss had not been discovered, Mrs. G might have bled significantly during the operation, perhaps requiring a blood transfusion and other treatment.

Think about it

  • Can you think of ways to lessen the likelihood of such problems occurring for other surgical patients?
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Case: Near miss with paralyzing drug
Side view of male physician in surgery

Background

During preparation for an operation, a vial of the neuromuscular blocking agent succinylcholine is inadvertently used instead of sodium chloride as a reconstitution agent.

Both vials have a similar appearance.

The anesthesiologist catches the substitution before any drug is administered and reports the near miss to the hospital.

Outcome

The hospital contacted the Institute for Safe Medication Practices Canada (ISMP).

ISMP Canada subsequently distributed a safety bulletin on the potential mix-up.

The manufacturer then made significant changes in the packaging and labeling of succinylcholine.

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Case: Near miss related to wrong-sided surgery
Close up of leg in cast

Background

A 60-year-old male is scheduled for surgery on his right knee.

After having checked the patient's medical record and confirming the site with the patient, the orthopaedic surgeon uses a permanent marking pen to initial the right knee in the centre of the operative field.

The surgeon arrives in the operating room and the left knee has been prepped and draped.

Outcome

The surgeon knows he must see the initials before making any incision or puncture. The problem is caught in time and the correct knee is operated on.

An analysis of this near miss resulted in several improvements in safety in the operating room.

"Operate through your initials" is one of several approaches used to help prevent wrong-sided surgery: preoperatively, the surgeon marks the initials of the surgeon's name on the site that is to be operated.

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Disclosure

Near misses sometimes need to be disclosed to patients, as described in disclosure.