Abstract
Purpose of review Near-miss investigations in high reliability organizations (HROs) aim to mitigate risk and improve system safety. Healthcare settings have a higher rate of near-misses and subsequent adverse events than most high-risk industries, but near-misses are not systematically reported or analyzed. In this review, we will describe the strategies for near-miss analysis that have facilitated a culture of safety and continuous quality improvement in HROs. Recent findings Near-miss analysis is routine and systematic in HROs such as aviation. Strategies implemented in aviation include the Commercial Aviation Safety Team, which undertakes systematic analyses of near-misses, so that findings can be incorporated into Standard Operating Procedures (SOPs). Other strategies resulting from incident analyses include Crew Resource Management (CRM) for enhanced communication, situational awareness training, adoption of checklists during operations, and built-in redundancy within systems. Summary Health care organizations should consider near-misses as opportunities for quality improvement. The systematic reporting and analysis of near-misses, commonplace in HROs, can be adapted to health care settings to prevent adverse events and improve clinical outcomes.
| Original language | English (US) |
|---|---|
| Pages (from-to) | 292-296 |
| Number of pages | 5 |
| Journal | Current Opinion in Otolaryngology and Head and Neck Surgery |
| Volume | 23 |
| Issue number | 4 |
| DOIs | |
| State | Published - Jul 1 2015 |
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Keywords
- Adverse event
- Aviation safety
- Healthcare improvement
- Near-miss
- Patient safety
ASJC Scopus subject areas
- Otorhinolaryngology
- Surgery
Cite this
Near-misses are an opportunity to improve patient safety : Adapting strategies of high reliability organizations to healthcare. / Van Spall, Harriette; Kassam, Alisha; Tollefson, Travis Tate.
In: Current Opinion in Otolaryngology and Head and Neck Surgery, Vol. 23, No. 4, 01.07.2015, p. 292-296.Research output: Contribution to journal › Article
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TY - JOUR
T1 - Near-misses are an opportunity to improve patient safety
T2 - Adapting strategies of high reliability organizations to healthcare
AU - Van Spall, Harriette
AU - Kassam, Alisha
AU - Tollefson, Travis Tate
PY - 2015/7/1
Y1 - 2015/7/1
N2 - Purpose of review Near-miss investigations in high reliability organizations (HROs) aim to mitigate risk and improve system safety. Healthcare settings have a higher rate of near-misses and subsequent adverse events than most high-risk industries, but near-misses are not systematically reported or analyzed. In this review, we will describe the strategies for near-miss analysis that have facilitated a culture of safety and continuous quality improvement in HROs. Recent findings Near-miss analysis is routine and systematic in HROs such as aviation. Strategies implemented in aviation include the Commercial Aviation Safety Team, which undertakes systematic analyses of near-misses, so that findings can be incorporated into Standard Operating Procedures (SOPs). Other strategies resulting from incident analyses include Crew Resource Management (CRM) for enhanced communication, situational awareness training, adoption of checklists during operations, and built-in redundancy within systems. Summary Health care organizations should consider near-misses as opportunities for quality improvement. The systematic reporting and analysis of near-misses, commonplace in HROs, can be adapted to health care settings to prevent adverse events and improve clinical outcomes.
AB - Purpose of review Near-miss investigations in high reliability organizations (HROs) aim to mitigate risk and improve system safety. Healthcare settings have a higher rate of near-misses and subsequent adverse events than most high-risk industries, but near-misses are not systematically reported or analyzed. In this review, we will describe the strategies for near-miss analysis that have facilitated a culture of safety and continuous quality improvement in HROs. Recent findings Near-miss analysis is routine and systematic in HROs such as aviation. Strategies implemented in aviation include the Commercial Aviation Safety Team, which undertakes systematic analyses of near-misses, so that findings can be incorporated into Standard Operating Procedures (SOPs). Other strategies resulting from incident analyses include Crew Resource Management (CRM) for enhanced communication, situational awareness training, adoption of checklists during operations, and built-in redundancy within systems. Summary Health care organizations should consider near-misses as opportunities for quality improvement. The systematic reporting and analysis of near-misses, commonplace in HROs, can be adapted to health care settings to prevent adverse events and improve clinical outcomes.
KW - Adverse event
KW - Aviation safety
KW - Healthcare improvement
KW - Near-miss
KW - Patient safety
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U2 - 10.1097/MOO.0000000000000177
DO - 10.1097/MOO.0000000000000177
M3 - Article
C2 - 26126125
AN - SCOPUS:84942792546
VL - 23
SP - 292
EP - 296
JO - Current Opinion in Otolaryngology and Head and Neck Surgery
JF - Current Opinion in Otolaryngology and Head and Neck Surgery
SN - 1068-9508
IS - 4
ER -