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Please use this identifier to cite or link to this item: http://hdl.handle.net/1942/10723

Title: Defining near misses: Towards a sharpened definition based on empirical data about handling processes
Authors: Kessels-Habraken, Marieke
De Jonge, Jan
Rutte, Christel
Issue Date: 2010
Publisher: Elsevier
Citation: Social Science & Medicine, Published online, 70(9), p. 1301-1308
Abstract: Medical errors in health care still occur frequently. Unfortunately, errors cannot be completely prevented and 100% safety can never be achieved. Therefore, in addition to error reduction strategies, health care organisations could also implement strategies that promote timely error detection and correction. Reporting and analysis of so-called near misses – usually defined as incidents without adverse consequences for patients – are necessary to gather information about successful error recovery mechanisms. This study establishes the need for a clearer and more consistent definition of near misses to enable large-scale reporting and analysis in order to obtain such information. Qualitative incident reports and interviews were collected on four units of two Dutch general hospitals. Analysis of the 143 accompanying error handling processes demonstrated that different incident types each provide unique information about error handling. Specifically, error handling processes underlying incidents that did not reach the patient differed significantly from those of incidents that reached the patient, irrespective of harm, because of successful countermeasures that had been taken after error detection. We put forward two possible definitions of near misses and argue that, from a practical point of view, the optimal definition may be contingent on organisational context. Both proposed definitions could yield large-scale reporting of near misses. Subsequent analysis could enable health care organisations to improve the safety and quality of care proactively by (1) eliminating failure factors before real accidents occur, (2) enhancing their ability to intercept errors in time, and (3) improving their safety culture.
Notes: Affiliation: a Eindhoven University of Technology, Eindhoven, The Netherlands; b Hasselt University, Belgium; c Tilburg University, Tilburg, The Netherlands
URI: http://hdl.handle.net/1942/10723
DOI: 10.1016/j.socscimed.2010.01.006
ISI #: 000277500400007
ISSN: 0277-9536
Category: A1
Type: Journal Contribution
Validation: ecoom, 2011
Appears in Collections: Research publications

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