patient safety & quality
patient safety & quality
By Kristina Pirollo-Ketchum, BA, AA, CHL, CRCST
Near Misses and Reportable Events in Healthcare
In addition to providing possibilities for proactive preventive measures, near misses present significant learning and healthcare system improvement opportunities.
At every level of care, honesty, clarity, and ongoing learning are necessary to guarantee patient safety.“
In the healthcare industry,“ near misses” are incidents that may have the potential to cause harm to patients but are stopped before they happen. However, incidents that are actually happening and where safety has been jeopardized need to be documented. They will improve patient safety and foster an equitable culture by reporting and learning about near misses. This study looks at the importance, issues with reporting, and solutions.
Importance of Near Misses
Near misses occur more frequently than adverse incidents and are crucial as a source of early warning, which is ideal for medical procedures. Erroneous handoffs, unclear instructions, or poorly designed equipment are examples of incidents that trigger the latent conditions and would not have been discovered until a patient was harmed. In addition to creating an environment of continuous reminder attention, this proactive practice will change the way that injuries resulting from errors are managed in order to prevent mistakes. This will ensure patient safety whenever errors cause damage and are discovered as soon as possible during the day.
Barriers to Reporting
Despite the well-established importance of reporting near misses, there are a number of challenges in consistently reporting possible events in the healthcare sector. The fear of blame or retribution is one of the challenges, as it cannot allow the staff to make mistakes or report near misses through fear. Also, reporting that does not produce tangible progress creates a sense that such an undertaking is in vain. The fact that the fast-paced clinical environments are characterized by time pressures also adds to the decreased probability of reporting due to the perception of documentation being a burden( Almansour, 2024). Together, these barriers lead to underreporting that provides high levels of blind spots with safety management and limits the possibilities of organizations to reveal risks and reinforce patient safety regimes.
Just Culture and Its Role
The just culture in healthcare pertains to the equilibrium in relation to the role of the responsibility of a specific individual and the organizational learning to guarantee that the safety becomes problematized without giving rise to any fear. This model draws the distinction between negligent acts or a reckless act, which results in accountability on top of such acts, and ignorance through methodological systemization, which moves the blame towards a systemic failure instead of individual failure( Dennison et al., 2022). Just culture encourages reporting of near misses and adverse events by assuring the staff who have had them that they are not unjustly blamed
By encouraging near-miss reporting, nurses in just cultures are able to successfully transform nearmisses into safer, more dependable healthcare practices.”
and giving credit for their participation where they deserve it.
Strategies for Improvement
In order to strengthen the position on patient safety, measures to enhance near-miss reporting should also be put in place. Simplified and easy-to-understand reporting procedures ease the workload for staff members and increase involvement. The completion of the feedback loop, which allows reporters and recipients of changes to be informed based on reports received, is one element that can increase the value of reporting. By rewarding and praising employees who report near misses, cultural elements of accountability and alertness are also fostered( Almansour, 2024). Developing innovative leaders to promote an atmosphere of open communication is another way to enhance the safe reporting environment.
In addition to providing possibilities for proactive preventive measures, near misses present significant learning and healthcare system improvement opportunities. At every level of care, honesty, clarity, and ongoing learning are necessary to guarantee patient safety. By encouraging near-miss reporting, nurses in just cultures are able to successfully transform near-misses into safer, more dependable healthcare practices.
Kristina Pirollo-Ketchum, BA, AA, CHL, CRCST, is an independent consultant and principal of Ketchum Konsulting, LLC.
References:
Almansour H.( 2024). Barriers preventing the reporting of incidents and near misses among healthcare professionals. Journal Health Management, 26( 1), 78-84. https:// journals. sagepub. com / doi / abs / 10.1177 / 09720634231167031
Dennison S, Freeman M, Giannotti N, and Ravi P.( 2022). Benefits of reporting and analyzing nursing students’ near-miss medication incidents. Nurse Educator, 47( 4), 202-207. https:// journals. lww. com / nurseeducatoronline / fulltext / 2022 / 07000 / Benefits _ of _ Reporting _ and _ Analyzing _ Nursing. 2. aspx? context =- FeaturedArticles & collectionId = 5
Isaksson S, Schwarz A, Rusner M, Nordström S, and Källman U.( 2022). Monitoring preventable adverse events and near misses: number and type identified differ depending on method used. J Patient Safety, 18( 4), 325-330. https:// journals. lww. com / journalpatientsafety / fulltext / 2022 / 06000 / Monitoring _ Preventable _ Adverse _ Events _ and _ Near. 9. aspx / 1000
28 • www. healthcarehygienemagazine. com • sept-oct 2025