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Safety
Make Your Near-misses Count
Nancy Burden
Publish Date: November 17, 2007   |  Tags:   Patient Safety

It staggers the imagination when you think of the number and types of potential mistakes that lie in wait for patients in any healthcare setting, especially one as procedure-intensive as a surgical center (see "Potential Near-miss Situations"). Yet with most facilities' high safety records, it's all too easy to be lulled into a false sense of security. All it takes is one error with devastating patient harm to shatter the spirit and confidence of the entire staff. But what about when we nearly make a mistake? As part of a comprehensive safety program, it's important to identify, report, analyze and discuss near-misses.

What's a near-miss?
A nurse grabs a vial from the medication supply, flips off the top and only then checks the name and finds that it's the wrong medication. Potential disaster is avoided, but does it sink in that this could have been a serious error? And how did the error occur, really? Did the nurse just grab from the wrong bin? Was the medication stocked in the wrong location? Did the nurse not look at the name of the medication? Was this a look-alike vial that should never have been stored where it was? Did the nurse then go back to ensure that the same medication was not likely to be mistaken again? Does it even register with the nurse that talking with her colleagues about this near-miss event could help raise awareness and prevent a true error?

Here's another common scenario. The operating room RN comes to the admitting area, walks to the bedside of a patient and begins the verification process. Only after several questions does the nurse become aware that she's dealing with the wrong patient. You could easily claim that this is what the verification process is all about and argue that this is not a near-miss event. You would be right on one level. On the other hand, shouldn't there have been a better process in place to avoid having the nurse question the wrong patient? What about a patient who's taken to the procedure room without a signed consent? Is it because the correct process wasn't followed somewhere along the way? Is this scenario recorded as a near-miss event if it's caught before the procedure begins? We surely have many more near-misses than we identify and report, or are even aware of.

Plan to learn
The ultimate goal is, of course, raising your staff's awareness and taking action to avoid small mistakes that can escalate into serious patient or provider harm. Components of a plan to encourage near-miss reporting should include the following.

  • Raise awareness. Are staff members and physicians even aware of what should be reported? The concept of reporting true errors or incidents is well-defined and understood, but it may not be as obvious when it comes to near-miss events. Raise awareness by discussing situations that present the potential for trouble. This very exercise may elicit disclosure of actual events that team members have experienced and never reported. Team brainstorming, sharing information from literature and posting a list of potential near-miss situations can be useful.
  • Establish an environment of trust. The culture of a center plays a role in the success of event reporting. No one is likely to self-report near-miss events if they expect to be humiliated or punished for their efforts. No one actually comes to work planning to make a mistake or to hurt another person. We are all capable of making errors. Team members need to feel safe and should be able to trust that their reports of actual or near errors will not result in punitive actions.

It's important to differentiate, however, between punitive actions and appropriate coaching. A potentially serious near-miss event is worthy of honest discussion between a team member and manager to help elicit any lesson it may provide. Positive outcomes of such discussions could include

  • the honest sharing of feelings and emotions;
  • an analysis of the how and why of the event;
  • a heightened awareness to avoid future occurrences;
  • staff support from facility management; and
  • a broader discussion of the event with the entire staff.
  • Encourage the team. Encouraging your staff to report near-misses means more than saying you won't punish those who do. Praise can be a strong motivator. Present those who share their foibles as positive role models. Managers can model behavior by sharing their own stories of averted errors.
  • Provide tools. Agree on a method for reporting near-miss events. Should a near-miss event be reported in the same manner as a true incident? Should there be a different, simpler form? Will electronic reporting be used? Are verbal reports adequate? Should near-miss reporting be anonymous? Should there be any distinction between self-reporting and peer reporting? Whatever the plan, the process must be well-communicated and the tools readily available to all team members.

Use it or lose it
So what good does it do to spend the time and effort collecting data about near-misses if you don't analyze, trend and share the information? None. If you ask your team members to be diligent in reporting their sometimes embarrassing and upsetting experiences, then you need to match their efforts to ensure that the information is used in the best way possible. Share the data in a positive light, educate and encourage all staff members to avoid similar errors, and preserve the dignity and confidentiality of those who were willing to share.

Think about the power of sharing. How eye-opening would it be to determine that a medication was placed in a wrong bin six times in a month when each nurse encountered the problem just once? How much more diligent would everyone be if they know that the center almost performed a wrong-site surgery due to a simple error that each person could easily have made? Shock and fear can strike a blow to complacency when we are aware of how close we, collectively and individually, can and have come to harming a patient or ourselves.

Potential Near-miss Situations

Here's a list of mishaps waiting to happen in every surgical facility. Challenge your staff to come up with their own ideas and discuss the ways they can be avoided.

  • calling a patient by the wrong name, and the patient responds
  • walking to the wrong bedside with medication and almost administering it
  • prepping or draping the wrong operative site
  • a physician walking into the wrong procedure room
  • receiving an order for a medication to which the patient is allergic
  • a nurse starts to pick up a tray that holds a sharp
  • a container holding a specimen is picked up and readied for another specimen
  • a patient's chart is placed at the wrong patient's bedside
  • wrong H&P on a patient's chart
  • a single case in a long schedule is cancelled and implants for the rest of day's cases are now out of order
  • storing topical, oral and injectable medications together
  • storing look-alike, sound-alike medications in close proximity
  • storing outdated or contaminated medication near regular stock
  • drawing up the wrong strength of medication
  • not allowing an alcohol-based prep solution to dry before applying drapes
  • using the sterilizer before you complete or read a spore test

— Nancy Burden, MS, RN, CPAN, CAPA

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