Near Failure Event: Characteristics And Examples

A near miss event , also called a near miss or near miss, is any action that could have originated an adverse event but which, luckily or due to a timely intervention, did not occur. In some literatures it is also assumed as a quasi-failure the medical error that, although it existed, had not been identified, so there is no record of it.

Identifying and analyzing near-misses makes it possible to identify where the possible weaknesses are in the care system and its strengths, since some element of said system managed to determine and stop the adverse event.

Near miss event

In turn, an adverse event is that damage suffered by the patient during the medical care process, causing the prolongation of hospitalization and / or some disability at the time of discharge.

The terms adverse events and near failures are generally used in healthcare quality control systems to address patient safety issues and hospital risk management.

Main features

In the health area, the registration of near-miss events is of great importance, given the search for quality of care and patient safety. The most relevant characteristics of the near miss event are the following:

– The near miss event has potential harm to the patient.

– By being detected before an adverse event occurs, it allows the health system to determine its strength.

– Some studies suggest that near-miss events can be of two types: those that are detected before reaching the patient and those that reach the patient but do not cause damage.

– The recurrence of the event implies a significant probability of serious adverse outcomes, which suggests that there are operational failures in the administrative health control.

– This type of event is statistically more frequent than adverse events, although most often they are not recorded as such.

– The factors or elements influencing this type of event are: possibility of human error, complexity of the treatment or procedure and deficiencies in the health system.

Human error

Regarding human error in the health area, it is considered as an aspect of great interest because although health professionals are among the most qualified and dedicated, they work in systems with imperfections.

It follows that the control of patient risks and the recording of failures in the system is considered of vital importance.

Complexity is not synonymous with effectiveness

The system should be designed in such a way that it is easy to do the right thing and difficult to make mistakes. However, this does not mean that it must necessarily be complex, because the more complex a system, from the systemic point of view, the more prone to the occurrence of errors.

A health care system in which the number of steps to be executed is reduced and that has a control of variables and clear actions, will avoid the deficiencies that could be latent in it.

The registration of each near-miss event in any system should be mandatory, although it is often overlooked. This situation means that the deficiencies of the system under study cannot be detected and this situation becomes the next possible adverse event.

Examples of near miss events

As explained above, some studies on the subject classify near-miss events into two types: those detected before reaching the patient and those that reach the patient but do not cause harm.

Based on this, the one detected before reaching the patient can occur due to strengths of the system itself and controls planned by the organization, or due to unplanned interventions (chance).

Case 1

A patient is considered to be admitted to the hospital and admitted to a shared room.

The nurse on duty sets out to administer the medications prescribed by the treating physician, but inadvertently hands the pills to the other patient in the room.

The other patient acknowledges that these are not their medications, does not take them, and alerts the nurse so that the medications can be administered to the correct patient.

This situation implies a high potential for harm, as a cognitively impaired or less conscious patient may have taken the wrong medications.

Case 2

The person in charge of the hospital pharmacy, when dispensing the patient’s medications, observes in the system that the patient is currently taking another medication that implies a known contraindication.

You decide to go to the supervising doctor, notify him that one of the doctors on duty has prescribed contraindicated medications, and request approval of the removal of the request.

The doctor agrees with the criteria and proceeds with the cancellation of the medical prescription, since an adverse event does not occur given the control carried out with the previous records in the patient’s medication system.

Case 3

An unconscious patient arrives at the emergency room, without relatives or companions. In the care, it is decided to apply a drug to which, curiously, she is allergic.

One of the resident physicians notices and immediately applies the allergy-mitigating medication. This yields, without causing harm to the patient, or affecting his next recovery.

Many of these events are not recorded, downplaying them. Correct reporting and control of near-failure events avoids the possibility of an adverse event occurring in patient care.

Themes of interest

Sentinel event .

References

  1. Agency for Healthcare Research and Quality (2017) ._ Adverse Events, Near Misses, and Errors. Taken from psnet.ahrq.gov
  2. González-de Jesús C, Santos-Guzmán J, Martínez-Ozuna G. Development of the ability to identify and report adverse events in undergraduate students. Medical Education Taken from: ems.sld.cu
  3. Sheikhtaheri, A. (2014). Near Misses and Their Importance for Improving Patient Safety. Iranian Journal of Public Health. Taken from ncbi.nlm.nih.gov
  4. The National Safety Council. Reporting near misses. Taken from safetyandhealthmagazine.com
  5. Society of Hospital Medicine (2006). Near Misses. Taken from the-hospitalist.org

Add a Comment

Your email address will not be published. Required fields are marked *