Near-miss analysis in a large hospital in southern Brazil: A 5-year retrospective study

Abstract

BACKGROUND: Near-miss analysis is an effective method for preventing serious adverse events, including never events such as wrong-site surgery. OBJECTIVE: To analyze all near-miss incidents reported in a large general hospital in southern Brazil between January 2013 and August 2017. METHOD: We performed a descriptive retrospective study of near-miss incidents recorded in the hospital’s electronic reporting system in a large non-profit hospital (497 beds). The results are expressed as absolute (n) and relative frequencies (%). Pearson’s chi-square test, Fisher’s exact test (Monte Carlo simulation) and linear regression were used. RESULTS: A total of 12,939 near-miss incidents were recorded during the study period, with linear growth in the number of reports. Near-miss incidents were most frequent for medication, followed by processes unspecified in the International Classification for Patient Safety framework, followed by information control (patient chart and fluid balance data), followed by venous/vascular puncture. The highest prevalence of reports was observed in inpatient wards, in adult, pediatric, and neonatal intensive care units, and in the surgical center/post-anesthesia care unit. Pharmacists and nursing personnel recorded most of the reports during the day shift. CONCLUSION: The most frequent categories of near-miss incidents were medication processes, other institutional protocols, information control issues, and venous/vascular puncture. The significant number of reported near-miss incidents reflects good adherence to the reporting system.

Identifying a list of healthcare ‘never events’ to effect system change: a systematic review and narrative synthesis

“…We excluded another 337 articles after reviewing the full-text citations largely because they neither identified individual NEs nor specified an existing framework (47%), or because they were non-scholarly (eg, media releases; 30%). Thus, our analyses were based on 367 articles 3 4 7–11 18–377. A full list of these articles and the information we extracted from them are found in online supplemental tables 1 and 2.…”

Determining Medication Errors in an Adult Intensive Care Unit

“…Röhsig et al’s [ 11 ] five-year integrative review on the cost of errors in the medication chain revealed that 94.7% of the authors analyzed the medication prescription stage at some point in their studies and that the average avoidable cost of this type of error corresponds to more than BRL 3 billion/year. Ranchon et al [ 36 ], when studying errors related to cancer patients undergoing chemotherapy treatment, reported that the 436 errors identified could generate 216 additional days of hospitalization and an avoidable cost/year of approximately BRL 624,186.38.…”

“…Among all hospital departments, Intensive Care Units (ICUs) are the hospital environment with perhaps the highest volume of prescribed drugs, which favors errors that can compromise patient safety, increase patient length of stay, and, consequently, increase hospital expenses [ 7 , 8 ]. ME prevalence in ICUs varies and has been documented in the literature for a long time [ 3 , 4 , 9 , 10 , 11 , 12 ].…”

Challenges of safety culture in Surgical Center: mixed methods study

“…So-called near misses or almost errors were less frequent in SC than in other units, such as hospitalization, intensive care and pediatrics ( 10 ) . On the other hand, the occurrence of adverse events of very high severity — known as never events — is alarming when it comes to the intraoperative and immediate post-operative period, such as surgery in the wrong laterality, wrong procedure and/or patient, retention of material inside the patient and electrocautery burns ( 11 ) .…”

“…Los llamados near misses o casi errores ya fueron menos frecuentes en los CQ que en otras unidades, como hospitalización, cuidados intensivos y pediatría ( 10 ) . Por otro lado, resulta alarmante la aparición de eventos adversos de muy alta gravedad – conocidos como never events –, en el intraoperatorio y postoperatorio inmediato, como cirugía en lateralidad incorrecta, procedimiento y/o paciente incorrectos, retención de material en el paciente y quemaduras por electrocauterización ( 11 ) .…”