Near Miss Reporting

Improved Essays
Many U.S. industrial sectors have experienced improved safety performance through near-miss reporting. For example, the offshore drilling sector experienced statistically significant lost-time injury rates (60% reduction of lost-time injuries) through near-miss reporting. In the offshore drilling industrial sector, a rate of 0 .5 near-miss reports per worker was correlated with a 75% decrease in lost-time injuries. The medical field in the U.S. experiences a large number of patient deaths as a result of medical errors. Near misses reported for transfusion medicine identified the following root causes: (1) samples collected from the wrong patient, (2) mislabeled samples and (3) requests from the wrong patient. Near-miss reporting was similarly …show more content…
This study also found that employees may be reluctant to report near misses due to fear of retaliation. The U.S. Nuclear Regulatory Commission (NRC) requires inspectors to review a reactor when a near miss event is reported. More than 200 reviews by inspectors were conducted by the NRC in 2010. Most reported incidents were low risk, but high-severity near-miss reports resulted in further investigation. The transportation services industry also benefits from reporting near misses. The Civil Aviation Authority (CAA), which regulates the United Kingdom’s aviation industry, uses near-miss reporting to record and assess potential safety incidents. The CAA maintains a near-miss reporting database to contribute to the improvement of air safety by identifying and mitigating hazardous conditions and situations. In comparison to other industrial sectors, the steel manufacturing industry has been slower to implement near-miss reporting practices. The research team reviewed existing work and visited a steel manufacturing mill to inquire about its safety program as it relates to near misses . The feasibility of implementing and maintaining a near-miss reporting program with a steel manufacturing company and environment was also assessed. By reporting, analyzing and disseminating near-miss information, hazardous situations and conditions can be identified and mitigated before a lagging indicator

Related Documents

  • Improved Essays

    The Joint Commission determines and sets goals for each year, which traditionally mirror federal expectations for healthcare. These goals generally highlight specific safety concerns that are problematic and affect healthcare systems nationwide. For 2016, hospital goals include patient identification, communication, medication safety, alarm safety, healthcare associated infection, falls, pressure ulcers, risk management and universal protocol (TJC, 2016). Within each goal are sub-goals that further address the concerns and identify evidence based practices to ensure success in the prevention of patient harm in each of these areas. During tracers, the auditors focus on these goals and are looking to validate that each of these goals is achieved through implementation of policies and procedures and they will review the processes in which these policies and procedures were implemented and checked for continuous…

    • 804 Words
    • 4 Pages
    Improved Essays
  • Decent Essays

    A popular report from the IOM Core Competencies was, To Err Is Human: Building a Safer Health System (1999). The report explored the status of safety in the United States healthcare delivery system. The report revealed major safety issues in hospitals. The problem with the report is that although it was conducted, there is limited research on how hospitals are fixing the problems revealed in this…

    • 505 Words
    • 3 Pages
    Decent Essays
  • Improved Essays

    Hospital Are Never Events

    • 128 Words
    • 1 Pages

    In continuation of risk factors, the employees’ failure to report a spill caused an occurrence of a Never Event, resulting in the fall of a patient whilst in a hospital setting. The strong litigation language of never events could result in the application of a strict liability standard […] medical liability, costs the nation between $76 billion and $102 billion per year in defensive medicine. For example, consider the case of a patient who falls […] total hip replacement. Under CMS guidelines, falls in a hospital are never events, because CMS believes that they should be preventable with due diligence. (Garrison LF and Labban AJ., 2008).…

    • 128 Words
    • 1 Pages
    Improved Essays
  • Improved Essays

    Three Mile Island Accident

    • 1075 Words
    • 5 Pages

    The accident at Three Mile Island (TMI), reactor two (TMI-2), not only halted the production of more Nuclear power plants in the United States but also taught us the importance of having: Workers with the appropriate knowledge, education, experience, and training with handling of nuclear material, maintenance, and facility operations. A chain of command clearly laid out, with whom needs to be informed, also how to accrue and convey accurate information to ensure safety and continuous operations. The need for protocols to be developed, rehearsed, and practiced, ranging from a minor issue all the way to a full plant nuclear meltdown. Background of TMI Accident Three Mile Island is located on a sand bar in the Susquehanna River south of Pennsylvania’s capital Harrisburg. Early in the morning on March 28th, 1979, one…

    • 1075 Words
    • 5 Pages
    Improved Essays
  • Decent Essays

    Patient Safety Rounds

    • 115 Words
    • 1 Pages

    The development of a working environment in which communication flows freely—as in the aviation industry where the “two-challenge rule” is practiced— is essential to the growth of an institutional safety culture.24 The Institute of Medicine has agreed: “Designing systems for safety requires specific, clear, and consistent efforts to develop a work culture that encourages reporting of errors and hazardous conditions, as well as communication among staff about safety concerns. ”25 In an effort to further enhance patient safety, build front-line staff confidence, and illustrate the responsiveness and support of management to the BCMA end-users, the collaborative team and management established Patient Safety Rounds, which is modeled after the Beth…

    • 115 Words
    • 1 Pages
    Decent Essays
  • Improved Essays

    Evidence Based Evaluation

    • 581 Words
    • 3 Pages

    The evaluation of evidence-based needs, implementation and outcomes is a vital part of the research process, according to Jacobs et al (2012). The need for evidence-based research is evaluated through Formative Evaluation, the implementation through Process Evaluation, and the outcomes by Impact Evaluation. The aim of this paper is to describe a Process Evaluation for the initiative of Daily Safety Briefings as a strategy to develop high reliability and reduce errors affecting patient safety. For many years the local organization has collected data, information that reflects patient and staff satisfaction, patient demographics, length of stay, and critical incidents.…

    • 581 Words
    • 3 Pages
    Improved Essays
  • Improved Essays

    There is great importance in regards to reporting medication errors within a facility. The report of medication errors trigger the healthcare staff to unveil what has gone wrong in their system of medication administration. In many settings reporting of medication errors are voluntary and the perceptions of the healthcare staff influence their decision-making process on whether to report the errors or not (Samsiah, Othman, Jamshed, & Hassali, 2016). In order for facilities to enhance their process and system, medication errors warrant reporting to discover weak areas and strengthen them for the future of patient quality.…

    • 442 Words
    • 2 Pages
    Improved Essays
  • Improved Essays

    Sometime mistakes take place, such as failure to check or record a lab finding, ordering the wrong drug, or entering a lab finding in the wrong patient’s chart. These mistakes are usually not enough to guarantee an occurrence of harm. Many serious medical errors result from violations of recognized standards of practice. Large sectors of the health care business are dominated by nonprofit providers. Their payments are made by third parties, the government, private insurers and self-insurers.…

    • 590 Words
    • 3 Pages
    Improved Essays
  • Superior Essays

    Medical Errors

    • 1523 Words
    • 7 Pages

    Accidents and medical errors occur when people less expect, so everyone should be aware and informed about what things should be done to prevent, and reduce, such incidents from occurring. Since informing everyone is one step into creating the ERM framework, healthcare organizations should get all the employees engaged in making an improvement in the healthcare facility. The method I will use the ERM framework to address risk which is, to first make sure all the employees know how important it is to give patients the best quality care possible. I will make sure to create a safe environment for everyone by getting people to staff to double check and help one another. Simple actions, such as making sure that employees get rid of chemical hazards, will help increase patient safety.…

    • 1523 Words
    • 7 Pages
    Superior Essays
  • Improved Essays

    This week we talked about medical errors. Rather than go with an article that discussed how medical errors are the third leading cause of death in the United States, I chose an article about the things patients can do that will help protect themselves from medical errors. According to the U.S. Department of Health and Human Services (2014), one in seven Medicare patients in hospitals experience a medical error. These errors can occur anywhere in the health care system and can range from harmless to deadly.…

    • 445 Words
    • 2 Pages
    Improved Essays
  • Improved Essays

    Just the other day, the question arise at work on whether we should report an incident or not. Back when I was in nursing school, they taught us to report any incident that happened on the unit including near misses. Despite the administration effort to encourage event reporting, some nurses are very reluctant on reporting an incident. Most health care workers think that the administration is tracking their mistakes, and they will eventually get in trouble. Will event reporting improve patients’ safety?…

    • 837 Words
    • 4 Pages
    Improved Essays
  • Decent Essays

    A Near Miss is an unplanned event that did not result in injury, illness, or damage – but had the potential to do so. An easy way to remember this is to use the term, “close call”. When these types of events occur, most people are just thankful they were not hurt and continue on with their day. However, when employees narrowly avoid an accident or injury, everyone should assume they are at risk of that same avoidance.…

    • 78 Words
    • 1 Pages
    Decent Essays
  • Improved Essays

    Burnout is a cause for many errors in the medical field, that can lead to the malpractice of nonmaleficence and beneficence. According to FDA, common causes also include “poor communication,…poor procedures or techniques” (Medication Error Reports, 2016). Studies done by John Hopkins Medicine researchers say that medical errors is “the third leading cause of death in the United States” (Allen, M., & Pierce, 2016). They had concluded that “more than 250,000 Americans die each year from medical errors” (Allen, M., & Pierce, 2016), leaving it behind twice the amount of lives that were lost in 2014 from heart disease and cancer.…

    • 653 Words
    • 3 Pages
    Improved Essays
  • Improved Essays

    Patient Safety Goals

    • 637 Words
    • 3 Pages

    The purpose of the NPSG is to attract attention to alarm hazards and to focus on the development of a systematic approach to identifying solutions that have the most direct relationship to patient safety (“The Joint Commission announces,” 2013). The goal is outlined in two phases: Phase I requires hospitals to recognize alarms as an organizational priority and to isolate the most important alarms to be addressed. Phase II, which needs to be implemented by January 2016, requires organizations to have specific policy and procedures established that are directed towards solutions for alarm management (Sendelach, Wahl, Anthony, & Shotts, 2015; “The Joint Commission announces,” 2013). In addition, The ERCI Institute has identified alarm hazards on their Top 10 Health Technology Hazards since 2007 and recommends a thorough assessment of alarm management (ERCI Institute, 2013).…

    • 637 Words
    • 3 Pages
    Improved Essays
  • Improved Essays

    The most common adverse event that jeopardizes patient safety is patient falls, or for documentation purpose, patient found on the floor. The most common preventable adverse event that jeopardizes the nurse accountability is patient falls. In my four years of nursing, I have had to complete one patient fall incident report, but I have assisted in the documentation of at least four, which was five too many patients fall. Morse fall scale is the fall risk assessment commonly used in the hospital setting. My plan is to educate the patient on their risk for falling, and take the Morse fall scale 2-steps farther.…

    • 1201 Words
    • 5 Pages
    Improved Essays