Near Misses: Free Lessons for Safer Care

You are a Registered Nurse working in a busy oncology unit. While assessing one of your patients, you notice that the bag of morphine used in his patient-controlled analgesia (PCA) system is running low. You go into the automated dispensing cabinet to get a new bag. As you walk out of the medication room, you ask another RN to meet you in the patient’s room, to double-check the PCA. While talking with your patient, you put down the new bag to tend to the alarm on his compression stockings. Your colleague enters and tells you she needs to perform the double-check now, before traveling with her patient. She notices that the medication you placed on the table was not morphine but fentanyl. Confirming the mistake, you complete your patient assessment and exchange the fentanyl to the automated dispensing cabinet for morphine, return to your patient, and hang the replacement bag of morphine with another colleague.

No harm was done. The potential error was caught before reaching the patient: there was no disruption in the patient’s PCA infusion, and the incorrect medication bag was never spiked, so no wasting occurred. Would you report the event in your hospital’s reporting system?

NEAR-MISS EVENTS

A near miss is an unplanned event that did not reach the patient, but which may have resulted in harm if it had. Also referred to as a “close-call” or “good catch,” the only difference between a near miss and an actual event is the outcome. Because near misses occur 3–300 times more often than actual adverse events, they lend themselves to quantitative analysis.[1–4] Furthermore, near misses can be studied from the perspective of the efforts used to recover the event, contributing to the ability of the healthcare system to respond proactively.[5] With so much insight to offer, the study of near misses is a critical strategy available to protect patients from injuries caused by medical errors.

REPORTING: AN ESSENTIAL SAFE PRACTICE

Since the onset of the patient safety movement just over a decade ago, healthcare organizations have been working to adopt the principles of safety science used in other high-risk industries, such as aviation and nuclear power. Voluntary reporting of adverse events and near misses is at the forefront of those industries, and the usefulness of near-miss reporting in particular has since spread to healthcare.[6] Voluntary reporting systems are relatively inexpensive, and their ability to capture events and near misses from a wide variety of areas and perspectives makes them the primary mechanism for detecting hazards in US healthcare institutions.[7,8] In fact, although the characteristics of the systems varied greatly, in a study of 1,652 US hospitals, all reported that they have centralized reporting systems.[9]

Legislation has also encouraged the voluntary reporting of events and near misses, in an effort to improve patient safety.[10] In most cases, however, healthcare provider involvement remains voluntary. Efforts to mandate such reporting are underway. The Pennsylvania Patient Safety Reporting System (PA-PSRS), for example, is a statewide database maintained by the Pennsylvania Patient Safety Authority, an independent agency created by the state to reduce harm from medical errors. The PA-PSRS is a widely recognized source of patient safety data. Reporting is mandatory, anonymous, and contains no identifying information. All information is confidential, nondiscoverable, and not admissible as evidence, features that all mirror successful reporting systems in other high-risk industries.[11] Of the more than 200,000 reports that PA-PSRS collects per year, 97% are about near misses.[12]

Additional efforts are led by various professional organizations. Since 2007, the New York Chapter of the American College of Physicians (NYACP) and the New York Special Interest Group of the Association of Program Directors in Internal Medicine (APDIM-NYSIG) have been working with the New York State Department of Health to collect data regarding near misses.[13] Voluntary, anonymous reporting via a web-based tool is an effective way of identifying vulnerabilities in our health systems and learning about strengths and weaknesses of the barriers that protect the patient from harm.[14] As of February 13, 2009, a total of 42 Internal Medicine Training Programs have completed the initial Near Miss Project education program, with an additional 4 programs committed to provide the training in the near future.

Factors That Influence Reporting

Reported incidents are known to under-represent the true state of affairs in healthcare.[15–17] Under-reporting is influenced by factors such as incident type, level of harm, lack of perceived benefit, time pressure, and fear of repercussions.[18] Moreover, because near misses by definition do not reach the patient, staff may feel especially unobliged to report them. Better understanding of the relative motivations and disincentives related to near-miss reporting within a particular institution will facilitate development of a more robust source of important practice-changing information in this area.

At Memorial Sloan-Kettering Cancer Center (MSKCC), numerous patient safety and quality initiatives have led to an increase in reporting over the past several years. Of all the institutional efforts, two factors are believed to be most directly related to near-miss reporting specifically: (1) moving to a web-based reporting system, and (2) efforts to feed the information back to direct-care staff.

Today’s patient care environment is complex and fast-paced, and clinician time is valuable. Having a reporting system that is sensitive to that is critical. To that end, many institutions have moved from paper-based systems to one of the many commercially available online reporting systems. In making that shift in 2007, Memorial Sloan-Kettering Cancer Center increased its reporting by nearly 40%. Before the online reporting system was introduced, near-miss data were systematically collected on only chemotherapy near misses. With the online system, reports of near misses began to flourish in a variety of categories. In 2009, of the 7,889 events reported at MSKCC, 35% were near misses ( Figure 1).

The use of an online reporting system not only eases the burden of reporting, but it also facilitates analysis and dissemination of data. The strength of reporting systems is in characterizing incidents and learning from them. Large numbers of near misses provide helpful data about the nature, frequency, and types of safety issues, while the text from a single report can send a powerful reminder to staff to maintain a healthy fear of today’s healthcare environment. Regardless of format, getting this information back to healthcare providers on the front line is a critical component in the learning process, and it assures staff that their concerns are heard.

At MSKCC, information from near misses is used in various presentations; this process has not only given staff insights that can influence their own practice, but also has led to more reporting. For example, when sharing a story of a near miss involving failure to communicate a piece of critical information in a handoff, a nurse responded with “that’s happened to me before… I didn’t know I could report it.” This opened a discussion of handoff issues that nurses had been finding ways to work around, using various strategies to get the information they needed. Not surprisingly, the literature suggests that nurses in particular tend to respond to events and near misses through these “workaround” approaches.[19] While this strategy helps to immediately remove the obstacle to patient care, it does nothing to decrease the likelihood of the problem recurring. Reporting, on the other hand, gets the information to those at liberty to do second-order problem-solving, allowing for systemic process changes to help prevent recurrence.

THE VALUE OF NEAR-MISS REPORTING: A CASE IN POINT

In considering again the case study presented at the beginning of this article, is there value in reporting this incident as a near miss? This example is very similar to a near miss reported at MSKCC, where all medication events and near misses are read by a multidisciplinary group on a biweekly basis. Investigation by the group revealed that, because of space limitations in the automated-dispensing cabinet, narcotics were being stored according to volume in the bag, making it easy for the nurse to remove the incorrect drug. Discussion of the issue spread from the group to other nurses on the inpatient units, and the increased awareness led to more reports of similar events. Ultimately, the data provided by the near-miss reports served as a basis to advocate for funding for additional storage units for the automated dispensing cabinet, allowing for discrete stocking of narcotics by drug, concentration, and volume, rather than just by volume alone.

CONCLUSIONS

Focusing on near-miss data may add more toward improving the quality of care than relying on adverse events alone.[6] Reporting near misses provides free lessons; by taking the time to report a near miss, staff can bring issues to the attention of a larger group more poised to evoke a system change that can prevent an actual event from occurring. Although most of the literature on reporting systems in healthcare focuses on the act of reporting rather than the follow-up that occurs as a result, strategies to include front-line staff in the communication loop are integral to the success of protocols addressing patient safety.[8,9]

References:

References

1. Callum JL, Kaplan HS, Merkley LL, et al: Reporting of near-miss events for transfusion medicine: Improving transfusion safety. Transfusion 41(10):1204–1211, 2001.

2. March JG, Sproull LS, Tamuz M: Learning from samples of one or fewer. 1991. Qual Saf Health Care 12(6):465–471; discussion 471–472, 2003.

3. Battles JB, Kaplan HS, Van der Schaff TW, et al: The attributes of medical event reporting systems. Arch Pathol Lab Med 122:231-238, 1998.

4. Petersen LA, Orav EJ, Teich JM, et al: Using a computerized signout program to improve continuity of inpatient care and prevent adverse events. Jt Comm J Qual Improv 24(2):77–87, 1998.

5. Reason JT: Managing the Risks of Organizational Accidents. Hampshire, England, Ashgate Publishing Limited, 1997.

6. Barach P, Small S: Reporting and preventing medical mishaps: Lessons from nonmedical near miss reporting systems. BMJ 320(7237):759–763, 2000.

7. Kohn LT, Corrigan JM, Donaldson MS (eds), Committee on Quality of Healthcare in America, Institute of Medicine: To Err Is Human. Building a Safer Health System. Washington DC, National Academy Press, 1999.

8. Levtzion-Korach O, Alcalai H, Orav EJ, et al: Evaluation of the contributions of an electronic web-based reporting system: Enabling action. J Patient Saf 5(1):9–15, 2009.

9. Farley DO, Haviland A, Champagne S, et al: Adverse-event reporting practices by US hospitals: Results of a national survey. Qual Saf Health Care 17(6):416–423, 2008.

10. Patient Safety and Quality Improvement Act of 2005. 109th US Congress, public law 109-41. Available at: http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=109_cong_public_laws&docid=f:publ041.109. Accessed on June 17, 2010.

11. Patient Safety Authority, Commonwealth of Pennsylvania: Pennsylvania Patient Safety Reporting System. Available at: http://patientsafetyauthority.org/PA-PSRS/Pages/PAPSRS.aspx. Accessed on June 17, 2010.

12. Greenberg C: Learning from adverse events and near misses. J Gastrointest Surg 13(1):3–5, 2009.

13. New York Chapter of the American College of Physicians: Near Miss Project Overview. Available at: http://www.nyacp.org/i4a/pages/index.cfm?pageid=3387. Accessed on June 17, 2010.

14. New York Chapter of the American College of Physicians: Near Miss Tracking Registry. Available at: http://www.nearmiss.org/. Accessed on June 17, 2010.

15. Stanhope N, Crowley-Murphy M, Vincent C, et al: An evaluation of adverse incident reporting. J Eval Clin Pract 5(1):5–12, 1999.

16. Weingart SN, Ship AN, Aronson MD: Confidential clinician-reported surveillance of adverse events among medical inpatients. J Gen Intern Med 15:470–477, 2000.

17. Sari AB, Sheldon TA, Cracknell A, et al: Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: Retrospective patient case note review. BMJ 334:79, 2007.

18. Lawton R, Parker D: Barriers to incident reporting in healthcare. Qual Saf Health Care 11(1):15–18, 2002.

19. Edmondson AC: Learning from failure in health care: Frequent opportunities, pervasive barriers. Qual Saf Health Care 13(suppl 2):ii3–ii9, 2004.