The Value of Learning From Near Misses to Improve Patient Safety: A Scoping Review

Abstract

Objectives: For years, health care has recognized that learning from near misses offers potential opportunities to reduce unintended harm to patients. However, these benefits have yet to be realized. It is assumed that effective actions are being implemented as a result of learning from healthcare near misses, leading to improvements in patient safety. A scoping review of the healthcare literature was undertaken to explore the value of learning from near misses in the improvement of patient safety. Methods:The scoping review was conducted on Ovid MEDLINE, Embase, and CINAHL. Eligible articles published since 2000 were included.Results: A total of 4745 articles were identified through the searches, with 19 included in the final review. The articles included one randomized control trial. All the included articles had evidence of action after reporting or investigation of near misses, with the majority showing evaluation of impact. Actions were human, administrative, and engineering focused. Impact evaluation focused on the reduction of near misses, but without consideration of patient safety outcome measures, such as harm. The review also noted limited availability of experimental research and variability in near-miss definitions and that actions are not just the result of near misses.Conclusions: Currently, health care assumes that reporting and learning from near misses improves patient safety. The literature provides limited evidence supporting these assumptions and shows that actions as a result of near misses are commonly aimed at the human. There is a need to prove the benefits of focusing on near misses in health care and for more system-level actions.

Incidence and type of voluntary reported perianesthetic medication errors in community veterinary clinics in Calgary, Canada

“…17 It is recognized that reporting and analyzing near misses are the first steps in reducing MEs. 18,19 However, there remains the mistaken belief that near misses are not errors but rather successful outcomes. 20 For example, a survey 18 of pharmacists found that 35.5% of those involved in an ME did not classify near misses as MEs.…”

Incidence and type of voluntary reported perianesthetic medication errors in community veterinary clinics in Calgary, Canada

“…17 It is recognized that reporting and analyzing near misses are the first steps in reducing MEs. 18,19 However, there remains the mistaken belief that near misses are not errors but rather successful outcomes. 20 For example, a survey 18 of pharmacists found that 35.5% of those involved in an ME did not classify near misses as MEs.…”

Updating Eindhoven: Clarifying the features of a patient safety near miss

“…However, without a clear, agreed and usable definition, near misses will continue to go unrecognised. [5][6][7] The authors set out to explore the features of a healthcare near miss to inform an evidence-based model. Those features are explored below, aligned with the literature.…”

“…As a result, learning is lost that would otherwise provide insights into contributory factors to incidents and activated controls to prevent those incidents. 4,5…”

“…However, there is known underreporting of safety events in healthcare, and even when reported learning is superficial. 4,5 If near misses are not recognised as such, there is a risk that efforts to learn will only focus on contributory factors, without attention to the controls involved.…”

From Blame to Learning: The Evolution of the London Protocol for Patient Safety

“…Another key strength of the systemic approach is its ability to learn. Each bad event, and indeed each near miss, becomes an opportunity to learn about the process of care and to improve it [ 41 , 42 ].…”

Incidence and type of voluntary reported perianesthetic medication errors in community veterinary clinics in Calgary, Canada

“…17 It is recognized that reporting and analyzing near misses are the first steps in reducing MEs. 18,19 However, there remains the mistaken belief that near misses are not errors but rather successful outcomes. 20 For example, a survey 18 of pharmacists found that 35.5% of those involved in an ME did not classify near misses as MEs.…”

Updating Eindhoven: Clarifying the features of a patient safety near miss

“…However, without a clear, agreed and usable definition, near misses will continue to go unrecognised. [5][6][7] The authors set out to explore the features of a healthcare near miss to inform an evidence-based model. Those features are explored below, aligned with the literature.…”

“…As a result, learning is lost that would otherwise provide insights into contributory factors to incidents and activated controls to prevent those incidents. 4,5…”

“…However, there is known underreporting of safety events in healthcare, and even when reported learning is superficial. 4,5 If near misses are not recognised as such, there is a risk that efforts to learn will only focus on contributory factors, without attention to the controls involved.…”

From Blame to Learning: The Evolution of the London Protocol for Patient Safety

“…Another key strength of the systemic approach is its ability to learn. Each bad event, and indeed each near miss, becomes an opportunity to learn about the process of care and to improve it [ 41 , 42 ].…”

Incidence and type of voluntary reported perianesthetic medication errors in community veterinary clinics in Calgary, Canada

“…17 It is recognized that reporting and analyzing near misses are the first steps in reducing MEs. 18,19 However, there remains the mistaken belief that near misses are not errors but rather successful outcomes. 20 For example, a survey 18 of pharmacists found that 35.5% of those involved in an ME did not classify near misses as MEs.…”

Updating Eindhoven: Clarifying the features of a patient safety near miss

“…However, without a clear, agreed and usable definition, near misses will continue to go unrecognised. [5][6][7] The authors set out to explore the features of a healthcare near miss to inform an evidence-based model. Those features are explored below, aligned with the literature.…”

“…As a result, learning is lost that would otherwise provide insights into contributory factors to incidents and activated controls to prevent those incidents. 4,5…”

“…However, there is known underreporting of safety events in healthcare, and even when reported learning is superficial. 4,5 If near misses are not recognised as such, there is a risk that efforts to learn will only focus on contributory factors, without attention to the controls involved.…”

From Blame to Learning: The Evolution of the London Protocol for Patient Safety

“…Another key strength of the systemic approach is its ability to learn. Each bad event, and indeed each near miss, becomes an opportunity to learn about the process of care and to improve it [ 41 , 42 ].…”