SMHS safety systems to prevent harm

Near-misses

A near-miss is an unplanned event that did not reach the patient, but which may have resulted in harm if it had. It is an impeded or interrupted sequence where an incident was intercepted before causing harm – for example, an incorrect medication was added to an infusion but it was identified and not administered. The WA Health CIM Policy 2015 (revised in 2018) describes a near-miss as, ‘An incident that may have, but did not cause harm, either by chance or through timely intervention’.

While it has been identified that the term near-miss is open to interpretation, it is agreed that the reporting, investigation and analysis of these incidents is essential to gain insight into how (small) system issues or errors develop into near misses and sometimes into adverse events. This insight often makes it possible for staff to identify the set of factors leading to the initial system or process issue, as well as those factors which enabled timely intervention and successful recovery of the situation.

When compared with adverse events, the added advantage of knowing the recovery factors enables staff to have a more balanced view of how patient safety can be improved. This enables staff to focus not only on preventative measures to address the system issues identified but also on the means of building in or strengthening the recovery factors that are involved once errors have occurred.

Read more about clinical incident management at SMHS and the Severity Assessment Code (SAC) categories.

See how we measure up

The graph below shows the number of near-miss events notified across SMHS hospitals using the Datix Clinical Incident Management System (Datix CIMS).

Figure 1: All clinical incidents ‘Notified” as ‘near-miss events’ from 2014/15 – 2017/18 for SMHS; including total ‘Notified’ and ‘Actual’ near miss events

Graph display that 47 clinical incidents were notified as near-miss events during 2014/15 to 2017-18, further analysis reveals that 4 of these clinical incidents were true or actual near miss events.

What do these figures show?
  • Figure 1 displays that 47 clinical incidents were notified as near-miss events during 2014/15 to 2017/18. Acknowledging that the term ‘near-miss’ is open to interpretation, further analysis reveals that 4 of these clinical incidents were true or actual near miss events. For example, a patient had been provided with the wrong name band and paperwork, however an adverse event was avoided as the error was identified during the completion of the theatre pre-operative check by nursing staff. The others clinical events were actual clinical incidents that did not result in patient harm.