Learning from Adverse Events and Near Misses

Incidence, nature and impact of error in surgery

“…Ideally, there should be a standard to which the error in the registry could be compared, including the proportion of errors that the system captures. It has therefore been suggested that a study should be conducted in which findings of trained expert observers present during the operation are compared with self-reported errors in the registry 31 .…”

Near-miss events are really missed! Reflections on incident reporting in a department of pediatric surgery

“…But was this near misses rate (3.5%) reliable? As reported by the Pennsylvania Patient Safety Reporting System (PAPSRS), an anonymous self-reporting system that collects over 200,000 reports per year, 97% are ''nearmiss'' events [16]. However, in some studies the overwhelming majority of adverse events and near misses remained unreported [17,18].…”

Development of a Measure of Patient Safety Event Learning Responses

“…Learning from small failures is argued to be essential for preventing related consequential failures (Cannon and Edmondson 2001); yet it appears that health care organizations could do more to take advantage of the kinds of ''free passes'' that more minor events and near misses afford them. Part of the challenge lies in the fact that minor PSEs, even if frequent, may not always be recognized at the ''sharp end'' as having compromised safety (Greenberg 2009). In addition, health care providers are overburdened in their daily operations and could not possibly report and respond to all PSEs.…”

“…Outside of health care, most studies of organization-level learning from failure look at whether organizations change their behavior in response to failure and the dependent variables are always failure/accident rates or costs (e.g., annual number of automotive recalls [Haunschild and Rhee 2004], bank closure rates [Kim and Miner 2007], airline accident/incident rates [Haunschild and Sullivan 2002], and rail accident costs per operating mile [Baum and Dahlin 2007]). In health care, failure events are not as easily defined and measured (Sutcliffe 2004;Ginsburg et al 2005;Pronovost, Miller, and Wachter 2006) because they are underreported (Lawton and Parker 2002;Greenberg 2009), have relatively low base rates (Rivard, Rosen, and Carroll 2006), and are easily confounded. This makes it useful to focus on more upstream learning processes as we try to measure learning from PS failure events.…”

“…This makes it useful to focus on more upstream learning processes as we try to measure learning from PS failure events. Moreover, as March and Sutton (1999) and others (Greenberg 2009) contend, using performance as the sole measure of learning runs the risk of missing out on important opportunities to identify and understand the micro-processes that contribute to learning outcomes. The health care literature is, however, relatively silent on the detailed processes of such learning (Carmeli 2007), although some case examples of how learning is taking place in the context of PS do exist (e.g., Sirio et al 2003).…”