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Author Nick Woodier, Charlotte Burnett, Bryn Baxendale & Iain Moppett |
| Abstract A near miss in healthcare represents a situation where a negative outcome for a patient was avoided, but it was a near thing. Healthcare has long struggled to embed reporting and learning from near misses, with limited clarity on what a near miss is. This study aimed to learn from industries beyond healthcare to identify the features of a near miss and clarify a definition for healthcare. A mixed methods study was undertaken with healthcare and industry safety experts providing their views on an example case study. The study found that definitions may not be completely clear in industries beyond healthcare, but there is still opportunity to learn. The features of a near miss were found to be orientated around the role of controls in an event sequence, that almost resulted in events reaching and impacting on a patient. The authors advocate for a broad definition for healthcare, with value in identifying where humans are required to intervene to prevent incidents occurring. These situations may offer opportunities to develop more robust controls in healthcare systems to provide barriers to incidents. |
