���THE IMPORTANCE OF NEAR MISS REPORTING IN OPERATING ROOM��“You Didn’t See It Coming”��

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Lydia Bundotich -Msc Med-Surg(APN)/ BSCN /KRPON

Moi Teaching and Referral Hospital-Eldoret, Kenya

Definition of near miss in health

• 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.”

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• 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 of or because it is intercepted”.

Introduction

• OR is prone to risks and incidents with 50% adverse events
• Surgical procedures expose patients to multitude of risks
• Healthcare professional espouse the principle “First do no harm”
• But patients are occasionally harmed by caregivers action or inaction
• Near misses occur far more frequently than adverse events
• Reporting is uncommon( “Why report when the error is corrected in time and the patient is not harmed?”)

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Continuation…..

• Study done in Turkey,90.2% of the participants knew the near-miss definition
• 37.0% encountered them
• The rate of those reporting the event was determined as 7.8%.
• The near-miss cases encountered by the participants were,
• Absence of site marking in 26.0%, not removing jewelry in 23.0%,
• Patient not starved in 18.0%,carelessness in 26.2% Boskurt S.2023)

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Examples of near miss events in OR

• Discrepancy between the scheduled procedure and the consent form.
• Wrong patient entering the operating room-
• Patients at the OR without proper identification.
• Site markings are ambiguous/unclear/Patients not involved
• Not all team members were present during time outs.
• when a needle is lost inside the patient or in transition between the surgeon and the scrub person realized immediately.

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More examples of near miss incidents in nursing and hospitals

• Medication errors,
• Infection Control,Equipment and Technology Failures
• Documentation and Communication Errors
• Emergency Response -Bleeding patient,opened before swab count
• Blood Transfusion and Lab Specimen Errors

How many such near misses might have occurred but go unreported?

Conceptual framework

• Practitioners often practice either of the following:
• Find, fix and forget or find, fix and report
• The first is common.
• The situations can be resolved as it does not cause actual harm to the patient
• Voluntary incident reporting systems improves patient safety.

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Conceptual framework (“Find and Fix”)

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Adapted from Sherman et al.

Importance of reporting a near miss

• Identifying, reduce and mitigating potential risks and hazards
• Building a culture of safety at workplace
• Learning from errors through trainings.
• Improve equipment and property maintenance
• Save time and money for the organization
• Mitigating financial, reputational, and legal risks

Barriers to near miss reporting

• Perception that if an incident does not reach the patient or cause any harm, it is not necessary to report
• Fear of punitive actions and litigations
• Blame culture
• Heavy workload and time constraints
• There is no followup-Poor feedback loop
• Manual ,ineffective/ no reporting systems at all

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How to avoid near misses in healthcare

• Enhance Communication: Establish clear, standardized communication protocols among staff.
• Continuous Training: Provide regular training on best practices and new technologies.
• Encourage Error Reporting: Foster a culture where staff can report errors and near misses without fear.
• Involve Patients: Educate patients about their treatments and encourage them to participate actively in their care.
• Conduct Regular Audits: Perform audits to identify risks and use feedback for improvement.

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Cont….

• Utilize Technology: Implement incident reporting software, electronic health records and automated systems to reduce human error.
• Promote Teamwork: Encourage collaboration across different healthcare disciplines.
• Manage Stress: Address stress and burnout among healthcare professionals.
• Update Policies Regularly: Keep policies and procedures in line with the latest best practices.
• Implement Checklists: Use checklists for procedures to ensure all steps are followed.

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CONCLUSION

• How is your organization doing in near miss reporting?

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• A useful indicator is the number of near misses reported as a percentage of the total number of incidents reported.
• If the percentage is less than 10% or 20%, then you may want to conduct an internal survey to find out why people are hesitant to report near misses.

Can we share success stories on near misses?

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