What causes near-misses and how are they mitigated?

Objectives: The objectives of this study were to determine the reasons hospital RNs attribute to near-misses and the techniques they used to mitigate these near-misses to prevent serious reportable events.

Background: Our health system developed this definition for the study: A near-miss is a variation in a normal process that, if continued, could have a negative impact on patients.

Methods: Study participants were RNs who completed a survey about a self-reported near-miss or another RN's near-miss they'd witnessed. Data collected included participant demographics, near-miss occurrence by day of week and time, near-miss type, and attributed causes.

Results: A total of 144 near-miss types were self-reported or witnessed by 123 respondents; of these, 43 (35%) self-reported a near-miss event and 80 (65%) witnessed a near-miss event. The respondents identified medication administration (19%) and transcription errors (10%) as the most frequent types of near-misses (N = 144). Selecting from 412 factors related to near-misses, more RNs attributed near-misses to personal factors than institutional factors. Top personal factors were not following policy and inappropriate decision making or critical assumptions. Top institutional factors were work-related interruptions and distractions, and poor communication about a patient. A total of 400 techniques were used to mitigate the near-misses, nearly one per causative factor identified. Top techniques used were stop, think, act, review (STAR) and verification of proper procedures or actions.

Conclusions: Hospital administrators should consider both personal and institutional factors when evaluating patient-safety programs. Education about mitigating techniques for near-misses is imperative for RNs.