Learning from near misses in an effort to promote patient safety - Patient Safety First

AORN Journal, Feb, 2003 by Aileen R. Killen, Suzanne C. Beyea

This month, AORN's Patient Safety First program will launch its web-based near-miss reporting system and database, which is called Safety Net. This reporting system and database will be used to collect national information about near-miss events in perioperative settings. AORN intends to analyze this information as part of its ongoing efforts to inform members and other perioperative clinicians about strategies that can be used to prevent medical errors in perioperative settings.

NEAR MISSES

What is a near-miss event? Some individuals call a near miss a close call, near hit, incident, or good catch. Most perioperative clinicians can recall an instance when a retained sponge was detected after an unresolved count, the day the wrong limb was prepped for surgery, or the time the wrong patient was transferred to the OR. If these issues are resolved before they lead to negative occurrences or outcomes, they are considered near misses. One simple and commonly used definition for a near miss is any event that could have resulted in negative consequences but did not. When near misses occur, most perioperative clinicians take a deep breath and sigh with relief, but near misses provide an opportunity to learn proactively from what some consider free lessons or just old-fashioned good luck.

Clinicians can learn from near misses because they occur much more frequently than actual errors or adverse events, allowing for quantitative analysis. Large numbers of near misses provide helpful data about the nature, frequency, and types of safety issues. Telling stories about near misses also is a powerful approach to sharing clinical knowledge. Most clinicians remember hearing near-miss stories told by more experienced practitioners. Reports of near misses can provide meaningful insights about how harm was avoided, as well as an understanding of the degree of patient risk. Sharing near-miss data is a critical strategy in efforts to protect patients from injuries caused by medical errors.

Why should near-miss events be shared with a national nursing organization? There are many reasons for maintaining a national database, but perhaps the most important is that AORN can disseminate reports about near misses effectively and efficiently to large numbers of perioperative nurses and other perioperative clinicians. Distributing safety information and alerts will help protect surgical patients from experiencing serious events or adverse outcomes. Data collected from a variety of clinical settings will allow content experts and researchers to identify patterns and trends and develop strategies to avoid or minimize harm.

USING AVIATION AS AN EXAMPLE

One example of a well-established national near-miss database is the Aviation Safety Reporting System (ASRS), which is used to collect and analyze confidential aviation incident reports that are submitted voluntarily. The purpose is to identify system or latent errors, as well as oven hazards, and to alert the industry about these errors. The ASRS receives more than 30,000 reports annually and issues alerts to the industry on a regular and as-needed basis. Most aviation experts agree that these efforts have resulted in an ever-increasing level of civilian airline safety. The ASRS operates independently of the Federal Aviation Administration and has no regulatory or enforcement powers related to civilian aviation. Many safety experts suggest that if health care could adapt aviation's methods, patient safety could be improved markedly. A national voluntary reporting system has great potential for improving patient safety and will enhance AORN's ability to identify issues, problems, and potential solutions. (1)

SAFETY NET

AORN's goal is to initiate a database similar to ASRS that will be used to collect data on perioperative near misses. The Association also will establish a process to alert clinicians about errors that affect surgical patients' safety. The system is intended to be strictly anonymous, and those who report near-miss events never will be asked for the patient's identity, the facility's name, or the names of the health care clinicians involved. The reporting system will be voluntary, and AORN will depend on nurses and other perioperative clinicians to submit reports.

Safety Net will be web-based, request some demographic information (eg, specialty, type of surgery), and provide space for reporters to record a narrative of the near-miss event. Sentinel events or events that lead to negative outcomes should not be reported using this database. AORN is limiting its data collection efforts to near misses. Actual events should be reported within the facility where they occur and to any appropriate regulatory authorities (eg, Joint Commission on Accreditation of Healthcare Organizations).

Reports of near misses throughout the country from all types of perioperative settings should help AORN identify problem areas that are amenable to clinical improvement. Learning from near misses helps everyone prevent larger or more serious problems. AORN's intent is to focus on learning from near misses by identifying hazards that can be improved immediately. The program will not focus on failures.