Leveraging Safer Nursing Care by Conceptualizing Near Misses as Recovery Processes

Jeffs, Lianne; MacMillan, Kathleen

doi:10.1097/01.ncq.0000347455.21171.49

Cited by 5 publications

(4 citation statements)

References 16 publications

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“…2006, Kanse et al . 2006, Jeffs et al . 2008, 2009) and patient safety in the mental health population (National Patient Safety Agency 2006, Brickell et al .…”

Section: Resultsmentioning

confidence: 99%

What near misses tell us about risk and safety in mental health care

Jeffs

Rose

Macrae

et al. 2011

Psychiatric Ment Health Nurs

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Accessible summary How near misses in the mental health sector are experienced is not well understood. Study findings elucidate the nature of near misses as both (1) vulnerabilities and risk associated with the mental health population (e.g. violence, aggression, fear and error proneness); and (2) ‘no‐harm events’ where clinicians or service users minimize or prevent harm from happening. Study findings have implications for practice, education, research and policy associated with recognizing and responding to safety threats in a timely manner to prevent harm to service users and providers. Abstract How service providers and service users view near misses in their daily practice within the rubric of patient safety events is not well understood. Further no studies were located that explored near misses specifically in mental health settings in Canada. In this context, a qualitative study was undertaken to gain insight into how service providers and service users (mental health clients or their family members) experienced and defined near misses. Eight (8) focus groups (n= 88) with service providers and 28 semi‐structured interviews with service users were conducted at three mental health care organizations. Content analysis was employed to the dataset that elucidated that near misses were (1) safety threats and vulnerabilities associated with experiencing mental illness; and (2) acts that avert harm and prevent something from happening. Findings are compared to what is currently known about in safety. Implications of findings for practice, research and policy are delineated.

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“…2006, Kanse et al . 2006, Jeffs et al . 2008, 2009) and patient safety in the mental health population (National Patient Safety Agency 2006, Brickell et al .…”

Section: Resultsmentioning

confidence: 99%

What near misses tell us about risk and safety in mental health care

Jeffs

Rose

Macrae

et al. 2011

Psychiatric Ment Health Nurs

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“…The significance of understanding these "near misses" is becoming widely accepted. [46][47][48][49] Using a prospective observational study design therefore provides a better representation of actual error frequency than simply measuring rates of iatrogenic harm.…”

Section: Discussionmentioning

confidence: 99%

Effect of a "Lean" intervention to improve safety processes and outcomes on a surgical emergency unit

McCulloch

Kreckler

New

et al. 2010

BMJ

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“…Critical to recovery processes is the concept of pattern recognition, defined as the ability of healthcare professionals to recognize cues and decipher patterns in their practice. [31] One nurse stated, "I think it's safer because in recognizing the potential harm to a patient, you want to prevent that as much as possible". Skill and experience are needed to be able to recognize a potential error, and then cognitively processes through the recovery from the potential error.…”

Section: Emotional Impact Of Errorsmentioning

confidence: 99%

Near misses: Nurses’ experiences with medication errors, power distance and error recover

Linnard-Palmer

Ngo

2015

Clinical Nursing Studies

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Background: Medication errors continue to be a major problem in health care settings in the United States. Research investigating factors contributing to medication errors continues in an attempt to reduce the incidence and save lives. Although electronic medical records and electronic prescribing technology have been reported to reduce the incidence, errors are continuing, some with significant impact on patient safety. A near miss is an incident that could potentially cause harm, was identified early and a mistake prevented. Little is known about near misses including the identification, intervention, prevention, and recovery. Nurses' perceptions, what led up to the incident, and how they went about correcting these incidents (recovery) provides insight to understanding what near misses are, where they take place, and how. Poor communication is directly linked to medication errors and near misses. In nursing, one communication variable that relates to errors and near misses concerns the concept of Power Distance and how it affects communication between nurses, colleagues and families. Power distance is based on a perception of inequality existing between individuals. This perception of power inequality may contribute to errors associated with communication such as near misses, actual errors, poor adherence to treatment and poor compliance with medications. Objectives: The aim of this study was to investigate nurse's experiences of errors, recovery processes, the concept of Power Distance and poor communication that have led to near-miss incidents. Methods: An on-line survey, developed for this mixed-methodological study, was completed by a total of 110 participants. Results: Analysis of the descriptive data demonstrated three general themes of types of near misses experiences: wrong medication to wrong patients; error caught just before reaching patient; and recognition of error, correction made before implementation. Thematic analysis disclosed six themes related to actual examples of near misses: patient identified the near miss; medication was already administered by another nurse; a systems error occurred with the computerized dispending unit; the five rights were breeched; timing of administration was incorrect; and the wrong medication was dispensed directly from the pharmacy. Three themes emerged concerning miscommunication and near misses: between healthcare team members; between shifts; and pharmacy verifying and approving wrong med/wrong dose. Power distance was only minimally found to be of concern to the participants in relation to near misses. Conclusions: Nurses' experiences with near misses, recovery and Power Distance illuminate the need to further investigate what recovery behaviors and prevention practices are taking place. Further knowledge in this area may improve communication, reduce errors and ultimately increase patient safety.

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Leveraging Safer Nursing Care by Conceptualizing Near Misses as Recovery Processes

Cited by 5 publications

References 16 publications

What near misses tell us about risk and safety in mental health care

What near misses tell us about risk and safety in mental health care

Effect of a "Lean" intervention to improve safety processes and outcomes on a surgical emergency unit

Near misses: Nurses’ experiences with medication errors, power distance and error recover

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