Know how to manage your near misses
Know how to manage your near misses
Information can help improve process stability
By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR
A near miss is an event that signals a weakness in the delivery of health care services. If the weakness is not identified and remedied, there could be significant consequences in the future.
Consider the following example: A patient is transferred to the intensive care unit after a particularly difficult surgery. The patient’s original post-op orders, written immediately prior to the surgery, were not discontinued, but due to the unexpected intraoperative complications, additional orders were written for the intensive care unit admission.
An order for an oral medication at 30 mg was continued and an order for 50 mg of the same medication was added. The error was noted before either medication was given. Some organizations calls this type of event a "good catch." Whatever the terminology used to describe these events, one thing is clear: A good near-miss management program is essential to patient safety.
Information about near misses can provide a prospective opportunity to improve process stability and avert potentially catastrophic adverse events.
The benefit of having a good near-miss management program is clear. Near misses occur much more frequently than more serious patient incidents. They also are relatively simpler to analyze and easier to resolve. Usually each sentinel event can be linked to a number of near misses that happened earlier.
By addressing the small failures more effectively, the likelihood of a sentinel event is reduced. Just by involving staff in identifying near misses, the patient care environment is likely to be made safer.
Seek out information
Regardless of the type of near miss, information about the event has to be sought after actively. Identification of near misses is not always obvious, and many near misses probably occur that are never recognized as such. It is important for the organization to have a consistent definition and perception of the near-miss event among all levels.
Don’t be too restrictive in the definition of a near miss. If the definition is narrow, the organization runs the risk of not gathering safety-related information simply because people don’t believe that the observed situations are reportable events.
Disclosure must be quick and simple. Completion of long forms will discourage reporting. Though the follow-up investigation may require a more thorough analysis, a quick summary of the near miss generally suffices for the majority of events.
Remember, even if filling out the disclosure form is a quick process, if retrieving a report form involves going to another room or scrolling through a web site, disclosure rates will decrease. If there is only one method of reporting near misses, people may be discouraged from reporting. Although there is a move in many health care organizations toward intranet disclosure systems, some individuals may not be computer-savvy.
Disclosure must be encouraged through several means. However, most important is that staff members know their reports are acted on quickly by management and the information is used to make needed and long-lasting process improvements.
Follow to closure
It is imperative that health care organizations have a system to ensure that all action items that result from the analysis of a near miss are followed until closure. If safety goals are being met, the process is working. If attainable goals are not being met, other targeted interventions are developed. Information about the process and causes of action plan failure are used to discover the barriers and make plans to decrease them.
Not only is it important to ensure that problems are fully resolved, it is also essential to the success of the near-miss management initiative. If staff members perceive that near misses are not acted on, they will not disclose near-miss information in the future. It is important to track all action plans resulting from the process and communicate them to the staff.
That lets employees know that the near-miss management process is working, and it increases accountability and recognition of the people implementing the interventions. A simple report that lists all the action plans that have been initiated and their status can be posted. Everyone will see that a certain number of interventions have been completed successfully, some are under way and producing results, some are under revision, and some are on hold for a stated reason.
Near-miss database
In addition to management of individual near misses, systems must be in place to manage and monitor aggregate near-miss information.
Near misses provide insight into potential failure points within individual processes and also can highlight weaknesses in the management system itself. As new incidents are added to the database, the organization can learn more about the stability of processes and effectiveness of systems. For example, suppose that a similar near-miss event has occurred in the past.
Suppose further that the previous incident occurred in a different department and the investigation was closed. If, in fact, the analysis of the previous incident was thorough and the right interventions were implemented, this would lead to the suspicion that there may be problems with the dissemination step of the organization’s near-miss management system.
Automated, computer-oriented information systems can greatly expedite management of near misses. It also is helpful to have some classification system to assist in the dissemination and processing of incidents.
Systematic collection and analysis of near-miss data should provide information that allows observation of patterns and trends over time. Such information is critical to reducing the frequency of future incidents.
A question that often arises in health care organizations is whether a large number of near misses is indicative of a safe or unsafe environment. It could be argued that a high number of incidents suggest unsafe situations.
However, simply the fact that near misses are identified suggests that employees are more safety-conscious and potential unsafe conditions are resolved proactively before a catastrophic event occurs. Hence, a large number of reported near misses are indicative of a safe health care delivery system.
If the organization’s senior leaders or groups external to the organization suggest that a high number of identified near misses translates to a high rate of sentinel events, this is likely to suppress the disclosure of near misses, which in turn will increase the risk of catastrophic events.
The goal of the near-miss management program should be effective evaluation and resolution of unsafe conditions, not reducing the number of reported events.
Near-miss management can improve the quality and safety of health care services significantly by identifying and remedying precursors that signal the potential for a significant adverse event.
Staff member involvement in all steps of near-miss management must be encouraged. Near misses often are less obvious than sentinel events and tend to have little if any immediate impact on patients or processes.
Despite their limited impact, near misses provide valuable insight into potential accidents that could happen. To reduce the likelihood of future catastrophic patient incidents and further improve the safety of health care services, organizations need to strengthen their near-miss management activities.
A near miss is an event that signals a weakness in the delivery of health care services. If the weakness is not identified and remedied, there could be significant consequences in the future.Subscribe Now for Access
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