Near-misses are an opportunity to improve patient safety: Adapting strategies of high reliability organizations to healthcare

Harriette Van Spall, Alisha Kassam, Travis Tate Tollefson

Research output: Contribution to journalArticle

11 Citations (Scopus)

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 languageEnglish (US)
Pages (from-to)292-296
Number of pages5
JournalCurrent Opinion in Otolaryngology and Head and Neck Surgery
Volume23
Issue number4
DOIs
StatePublished - Jul 1 2015

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Patient Safety
Aviation
Organizations
Delivery of Health Care
Quality Improvement
Safety
Safety Management
Checklist
Industry
Communication

Keywords

  • Adverse event
  • Aviation safety
  • Healthcare improvement
  • Near-miss
  • Patient safety

ASJC Scopus subject areas

  • Otorhinolaryngology
  • Surgery

Cite this

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