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Learning from near-misses

I was delivering some training recently at a hospital which was using the latest version of Datix, the instant reporting system. They have the newest release in place, which allows you to report no-harm, near-miss incidents; something the old system would not let you do. We checked the drop-down menus together and confirmed this capability was included.

During a quiet moment later that day with the senior management, I asked about their near miss reporting. They gave me a puzzled look, and asked what I meant by near miss?

When I explained what I meant, they told me they didn't do that. This prompted a conversation about how near misses are the luck element that results in not harming patients.

It became clear that the management at this hospital had not thought of near-miss reporting in this way before. They were bright people and very nice people, very well-intentioned, but it just hadn't occurred to them.

What it seems we often do at Atrainability is point out the obvious.

By getting members of critical teams to think about those danger areas they already know about, and they need to be proactively addressing, it helps them recognise the tip of the iceberg.

These are the dangers sitting right in front of us. But the real threat is submerged below the surface. When no harm is done, there are no visible means of damage caused.

Analysing near misses comes back to root cause analysis. There will probably be several underlying conditions at play.

For example, if you have a nurse who is going to be scrubbing with a surgeon, who has never carried out that procedure before, compared with a nurse who has. The nurse who has carried it out before is likely to know what the surgeon needs next before they even ask for it.

In that scenario, it's important to know before you get started whether your colleague knows what they are doing, or not, because in one case it's going to be a bit longer, and require a lot more communication.

From my background as a pilot, a mandatory reportable incident is anything which had the potential to cause harm. It's all about that word, potential.

Where potential to cause harm is identified in the medical profession, it's essential those near misses are analysed and understood, before changes are introduced to reduce that potential in the future.

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