The plethora of data we frequently face during quality, risk management and process improvement activities can be daunting. There is one event very frequently ignored or overlooked with the potential for transformative change, the near miss.
Dashboards and reporting systems often contain data elements of little use. The newest member of the process improvement team asks "Why do we track that data element?" the frequent response is "Because we always have tracked it" Recent articles in JAMA, a comprehensive NAM report along with resources from AHRQ and NQF highlight the quality measure problems.
Near misses are ignored for a variety of reasons. First, the absence of harm is viewed as a reason to classify as insignificant. "No harm no foul" attitudes persist. No matter how egregious the facts, because there is no clear harm, people can be dismissive. For example, I witnessed the recognition that radiology studies were performed on the wrong patient. This "never event" was viewed as unimportant because the studies performed on the incorrect patient and the correct patient, who was imaged soon after, were reported as normal. Second, people see near misses as not fulfilling the criteria for a reportable event. Lastly, near misses fall into the broad category of alarm fatigue and data overload.
Mistakes, errors and oversights are opportunities to improve. Whatever the rationale, use near misses constructively. Recognize near misses as a blessing since there was no harm and correcting the the problem now can avoid a potential future injury. I am not suggesting that all near misses require an exhaustive RCA or even detailed reporting but at a minimum if there are multiple similar near misses or the potential harm is catastrophic, then further scrutiny and tracking is mandated. Each near miss can be assessed based on the individual facts. The time is now to add the identification and review of near misses to enhance care.
Copyright Nicolas Argy 2016 Health/Business Consultant/Educator, Patient Safety, Quality, Risk Management, Public Health Advocate, Witness Prep