The Near Miss
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"It could be the Pyxis drawer was empty when you went to get a medication," she says. Some staff may not understand why that's a near miss, she adds, so she asks them, " 'What happens when your patient is coding, you go into the Pyxis machine that's supposed to have 10 vials of atropine to save someone's life, but the drawer is empty?' Then it becomes an incident."
Lapponese encourages floor staff to report every near miss they can. "I say, 'When you report a near miss, that's you documenting that you're doing your job.' "
Now, the Common Formats system is capturing near misses that may never have been fully appreciated before, says Montefiore's patient safety officer, Jason Adelman, MD, MS.
For example, recently a patient with a pacemaker was sent downstairs for an MRI, which could have caused the pacemaker to misfire. "Thankfully the MRI staff caught it in time ... but it was much closer to happening than we were comfortable with." Now, processes are in place to make sure that can't happen again.
Adelman says the data is revealing something that has surprised Montefiore leadership: that 10% of reported events are near misses. That is prompting a campaign to increase near-miss reporting even more in hope of learning how processes might be improved.
Karen P. Zimmer, MD, MPH, FAAP, medical director of the ECRI Institute PSO, which has 700 hospitals across the country, says "regardless of what the outcome is, if there's a broken process, there's a broken process. We often say the near misses are wonderful lessons to learn from because they're free. And they help us learn what safeguards prevent an incident from reaching the patient," and share that with other hospitals.
Another benefit of using Common Formats is how it clarifies what hospital staff should report, especially in the case of near misses or incidents that are seen as just part of the downside of caring for very sick patients, such as an unintended drug side-effect.
Christina Tickner, RN, MSN, CPHQ, interim director for the Los Angeles County Department of Health Services Quality, which oversees quality for four hospitals, including LA County USC, gave an example of how double-checking a patient's file may turn up a medication that shouldn't be there. "They caught it. But it prompts a look back at the process, whether it's a pharmacy issue or an input issue."
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