Sivakumar Murugesan.

   Consultant: Hospital Project, Patient Safety and Quality Improvement 

Establishing patient safety reporting systems is an important step for improving patient safety. Using such systems, healthcare organizations can collect, analyze, and share information about patient safety. A variety of incidents including adverse events near misses and medical errors may be considered reportable, however, there are some controversies about near misses. Additionally, this concept has been defined differently.

WHO defines a near miss.

WHO defines a near miss as “an error that has the potential to cause an adverse event (patient harm) but fails to do so because of chance or because it is intercepted”. According to the Institute of Medicine, a near miss is “an act of commission or omission that could have harmed the patient but did not cause harm as a result of chance, prevention, or mitigation”. Some definitions had an emphasis that a near miss is an incident that did not reach the patient at all because it was intercepted before reaching the patient; however, others emphasized that a near miss may reach the patient but does not cause harm. Therefore, some researchers have focused on the interception of an error and others focused on the prevention of harm. These controversies may result in confusion as to whether a specific incident should be reported or not.

A study suggests that we should distinguish two factors (“reaching the patient” and “patient harm”) and define two separate concepts: “near miss” and “no harm incident”. This framework is appropriate but fails to consider the reason for interception or harm prevention (such as chance or intervention). We should consider this factor because it can provide different information about the incidents.

The importance of reporting such incidents

Patient safety experts argue that the root causes of near misses and adverse events are similar. Therefore, detecting the root causes of near misses can help us to correct these causes and prevent future adverse events. The goal of a reporting system is to identify and remove the root causes of incidents (not merely counting the events) and this can be achieved by near misses . Furthermore, a small percentage of incidents lead to adverse events. Thus, the emphasis on reporting adverse events results in a small database with insufficient data for analysis. Therefore, by reporting near misses, we can have a large database for analysis.

Additionally, the reporters of near misses are not at the risk of blame, shame, or legal litigation. Therefore, this may positively influence the staff's willingness to report these incidents without any fear. Even, the reporters may be prized or awarded because of their efforts for preventing harm.

Identifying near misses

There are several potential ways to identify close calls. The most common methods include direct reporting by health care workers and also less obtrusive methods, such as active clinical monitoring. Patient safety reporting systems play an important role in identifying close calls. Reporting systems allow incidents to be analyzed in terms of contributing factors and to follow trends over time.

It is desirable to have multiple channels by which frontline health care workers can report incidents including close calls. These might include paper-based reporting, online reporting, email reporting, and even phone calls to a recorded hotline from clinicians who observe incidents. Online reporting to a well-publicized central system is probably most effective. Direct reporting of near misses does not have to be limited to health care workers. Patients and families can report near-miss incidents.

Importantly for institutions, it is not necessary to capture every incident or every near miss that occurs. Given that the true prevalence of near misses is likely quite high, capturing even a fraction of these can allow for robust analysis. In fact, capturing every adverse event or near-miss can be overwhelming and maybe undesirable, as in the case of repeated reporting of the same incident.

Active clinical monitoring occurs when data collection about key elements of care is built into the clinical process. One example is the charting of vital signs by anesthesiologists in the operating room. Another is a systematic recording by pharmacists of erroneously written prescriptions. A third is a required checklist to be completed before placement of a central venous catheter that is then added to the medical record. All of these could help to capture near misses.

The most effective methods of reporting use automated systems that continually record elements of care and can detect errors. This includes "smart pumps" (infusion pump that alerts operators when it is infusing outside of pre-configured limits), bar-code systems for medication administration and patient identification, and an increasing number of IT-based solutions. For example, a recently developed system monitors hand washing and identifies cases in which the proper hand hygiene protocol is not followed. When linked to information about the frequency of patient outcomes, these systems can identify both errors and near misses and then correlate those with patient outcomes.

Benefits of studying near-misses

Studying close calls has several advantages over examining either medical errors or adverse events. First, they provide information on both active and latent errors in the health care system. Active errors occur where health care, usually in the form of a frontline health care worker, comes into direct contact with a patient. An example would be if a nurse were to pick up the wrong syringe and inject the patient with atropine rather than LMWH. These are generally readily apparent—unlike latent errors, which are features of an organization or design that are less apparent but that allow errors to occur. An example of this is the look-alike packaging of atropine and LMWH syringes. Importantly, the causes of close calls in health care appear to be very similar to the causes of incidents that cause harm—the same factors contribute to errors that sometimes cause harm, and sometimes do not.

Second, close calls are more frequent and much more frequently reported than adverse events, providing more grist for the analytic mill. Close calls provide a more robust opportunity to examine individual practice and systems of care in error analysis. This may reveal the nature and location of what James Reason refers to as "error traps" where errors tend to recur.

Third, close calls are generally less fraught with emotion and stress than adverse events. As the patient is not directly harmed, close calls are divorced from worries about liability claims. They are easier to investigate as health care staff are less paranoid about discussing errors that might have occurred. In addition, providers are less likely to be emotionally invested or involved with near misses compared to adverse events that lead to harm.

Finally, studying close calls makes it possible to identify recovery strategies in situ. Fortunately, most errors are detected before they cause harm and are corrected or mitigated. For example, the nurse discharging the patient from the ED might have asked the patient to show her/him the contents of the brown paper bag containing his medications, thereby detecting the unwanted atropine syringes. In the case of errors that go unnoticed, there is no attempt at recovery. In case of injury, there may have been no attempt at recovery, or the attempts may have been unsuccessful. Understanding recovery can lead to designing systems that are more resilient. It can also help to design systems to capture errors before they cause harm.

Frequency of near misses relative to medical errors

Because of the lack of systematic mechanisms to capture errors and their consequences, it is not certain how common near misses are relative to errors and to adverse events. However, it has been estimated that for each preventable death, there are between 7–100 close calls that occur before it. Certainly, near misses are reported much more frequently than adverse events. For example, the Pennsylvania Patient Safety Reporting System collects more than 200,000 reports per year, 97% of which are close calls. One can imagine a "safety pyramid" in which errors form the base, followed by close calls, with incidents that cause harm at the top.

In conclusion, near misses and no harm incidents can provide valuable information much of which cannot be captured by adverse event reporting systems, therefore, reporting such incidents should be encouraged; however, the necessity of developing a large database and employing more staff for data management should also be considered.