nursing near miss 2024-2025
nursing near miss 2024-2025
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,” as defined by the Institute of Medicine. Another definition is “an error discovered before it reaches the patient”.
A “near miss” is defined by the WHO as “an error that has the potential to cause an adverse event (patient harm) but fails to do so because it is intercepted or by chance.” “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,” the Institute of Medicine defines a near miss. Another definition is “an error discovered before it reaches the patient.” I’ve looked over more than twenty definitions; This idea should be used to describe an event that has the potential to cause harm but ultimately does not. This is generally agreed upon. However, there are significant in-depth disagreements. A near miss was defined as an incident that was intercepted before reaching the patient and did not reach the patient at all, according to some definitions. However, others emphasized that a near miss does not necessarily harm the patient. As a result, some researchers have focused on correcting errors while others have avoided harm. These discussions might bring about disarray as to climate a particular occurrence ought to be accounted for or not. According to a study, we should differentiate between two factors—”reaching the patient” and “patient harm”—and define two distinct concepts: close call” and “no harm incident” This framework is right, but it doesn’t take into account the reason for intercepting or preventing harm (like by chance or intervention). This factor ought to be taken into consideration because it might provide different details about the incidents. As a result, I recommend the following category:
A. Near misses
- Type 1: An incident that does not reach to the patient because of formal and planned interventions and programs (previously developed by the organization)
- Type 2: An incident that does not reach to the patient because of chance or unplanned interventions
- B. No harm incidents
- Type 3: An incident that does reach to the patient but does not cause harm because of early detection, interventions and treatment
- Type 4: An incident that does reach to the patient but does not cause harm because of chance
The significance of reporting such incidents Experts in patient safety assert that adverse events and near misses share similar underlying causes. Therefore, identifying the underlying causes of near misses can assist us in addressing these issues and avoiding adverse outcomes in the future. Near misses can be used to achieve the goal of a reporting system, which is to remove the root causes of incidents rather than simply counting the events. Additionally, a small number of incidents result in negative outcomes. As a result, there is a small database with insufficient data for analysis as a result of the emphasis placed on reporting adverse events. We can therefore create a substantial database for analysis by reporting near misses.
In addition, there is no risk of blame, shame, or legal action for the reporters of near misses. As a result, the staff may be more likely to report these incidents without fear as a result of this. Even so, the reporters’ efforts to prevent harm may earn them recognition or awards.
Error management practices’ strengths and weaknesses can be learned from incidents like these that are reported. The type 1 incidents do not indicate a weakness in the organization. They show that the actions and plans that were planned ahead of time are correct. As a result, we are able to gather data to assess these plans’ efficacy. The healthcare system (organization) is failing to design appropriate formal measures to prevent the events from continuing in the other three categories. As a result, we are able to gather data regarding our deficiencies in the creation of formal preventive mechanisms and the stages of our process that call for such mechanisms. Additionally, reporting type 2 near misses assists healthcare organizations in determining whether or not to formalize effective unplanned and accidental actions. The type 3 incidents enable us to evaluate our procedures for detection and intervention as well as the increased utilization of resources for the purpose of detecting and mitigating the incidents. Additionally, the organization’s inability to catch events before they reach the patient is demonstrated by the type 4 incidents. As I mentioned earlier, each of these four kinds of incidents offers distinct perspectives on healthcare errors and error management strategies. In conclusion, reporting near misses and no-harm incidents ought to be encouraged because they can provide valuable information, a lot of which cannot be captured by adverse event reporting systems; However, additional staffing for data management and the creation of a large database are both essential considerations.
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