Using “Near Misses” Analysis to Prevent Wrong‐Site Surgery

Yoon, Richard S.; Alaia, Michael J.; Hutzler, Lorraine; Bosco, Joseph

doi:10.1111/jhq.12037

Cited by 34 publications

(40 citation statements)

References 8 publications

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“…‘Near misses’ are potentially harmful events for a patient, not causing damage due to chance or mitigation (Yoon et al. ). In the published literature, incidents of near misses are reported 300 times more often than actual errors (Haugen et al.…”

Section: Discussionmentioning

confidence: 99%

Clinical risk management – a 3‐year experience of team timeout in 18 081 ophthalmic patients

Weingessel

Haas

Vécsei

et al. 2016

Acta Ophthalmologica

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Section: Discussionmentioning

confidence: 99%

Clinical risk management – a 3‐year experience of team timeout in 18 081 ophthalmic patients

Weingessel

Haas

Vécsei

et al. 2016

Acta Ophthalmologica

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“…Since there is a general under-reporting of adverse medical events, such as medication errors and near misses and malpractice claims this has led to many healthcare providers not recognising the national patient safety problem as applicable to their organisation. [30] However, in the context of patient safety, where the main goal is to reduce avoidable harm resulting from healthcare, experts argue that, "events reporting" have the potential to contribute continuously to learning, and in order to facilitate effective safety learning, near miss and incident data must be interpreted as a concern and the risk factors and suggest that a culture of learning is a useful intervention for improving patient safety. [31,32] The authors analysed five studies that evaluated different methods of critical incident reporting.…”

Section: Reportingmentioning

confidence: 99%

A critical appraisal of what organisational approaches are pivotal to improve patient safety

Kim

Terry

Jang

et al. 2020

JHA

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Background: Patient safety remains a priority for healthcare organisations globally. There remains little consensus regarding the extent of this issue and the resultant impact on both individuals and communities. Aim: Our study aims to provide healthcare organisations and decision makers with increased information regarding predictive risk factors to enhance patient safety, and develop an organisational culture of safety. Methods: This paper reviews current literature regarding patient safety and presents predictive risk factors and recommendations for healthcare organisations globally to measure and monitor patient safety. Results: Three categories of organisational factors promoting safety culture were identified – Focusing on system/culture, management support and team work and event reporting. Conclusions: This review strove to identify and discuss the predictive risk factors for patient safety and support the importance of a positive organisational culture and strong leadership in monitoring and reducing patient care errors and improving patient care in healthcare setting.

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“…Yoon et al completed a preintervention and postintervention study of surgical near‐miss or good catch events. The project team educated all health care team members about reporting good catch events and encouraged staff members to do so, resulting in a significant decrease of never events during a nine‐month period.…”

Section: Review Of the Literaturementioning

confidence: 99%

Good Catch Campaign: Improving the Perioperative Culture of Safety

Lozito¹,

Whiteman²,

Swanson-Biearman³

et al. 2018

AORN Journal

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Although health care workers feel pressure to reduce adverse events in the perioperative department, a lack of education, communication, and leadership can prevent hospital personnel from reporting good catches. The purpose of this evidence-based quality improvement project was to improve the culture of safety in our perioperative department by implementing the Good Catch Campaign. An interprofessional team led staff member education after implementing a standardized electronic reporting system and debriefing process to occur after good catches. Staff members reported 391 good catches from all perioperative areas during the six-month postimplementation period. Staff members completed the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture before and six months after implementation; scores improved in five areas: communication openness, feedback and communication about error, frequency of event reporting, nonpunitive response to error, and organizational learning and continuous improvement. The campaign was a successful strategy for improving perioperative patient safety.

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Using “Near Misses” Analysis to Prevent Wrong‐Site Surgery

Abstract: A program designed to educate physicians to the importance of decreasing near misses for wrong-site surgery is effective. When analyzing the literature, it is clear that the reduction in near misses observed in this study decreases the likelihood of a wrong-site surgery.

Cited by 34 publications

References 8 publications

Clinical risk management – a 3‐year experience of team timeout in 18 081 ophthalmic patients

Clinical risk management – a 3‐year experience of team timeout in 18 081 ophthalmic patients

A critical appraisal of what organisational approaches are pivotal to improve patient safety

Good Catch Campaign: Improving the Perioperative Culture of Safety

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