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ISMP survey helps define near miss and close call

From the September 24, 2009 issue

We extend our sincere thanks to more than 3,800 readers who participated in our survey regarding the definition of a near miss! ISMP agrees with the vast majority of respondents (88%) who defined a near miss as an error that happened but did not reach the patient. These errors are captured and corrected before reaching the patient, either through chance or purposefully designed system controls that have been put in place. Thus, reporting near misses can help to evaluate whether capture opportunities are functioning poorly—if they are fortuitous—or functioning well—if they are part of the system design, consistently implemented, and routinely effective.

Only 3% of respondents defined a near miss as an error that reached the patient but did not result in harm. Yet, this is closer to how a near miss is defined by some state reporting programs and the Agency for Healthcare Research and Quality (AHRQ) (www.psnet.ahrq.gov/glossary.aspx). According to the AHRQ definition, a near miss is an “event or situation that did not produce patient injury, but only because of chance.” Thus, the good fortune of not harming a patient might reflect how robust the patient is or how fortuitous a timely intervention by the provider may be. The problem with the AHRQ definition is two-fold: 1) It does not clarify whether the harmless error that resulted in the “event” or “situation” reached the patient; and 2) It fails to foster ongoing evaluation of system controls that can help capture errors or prevent patient harm once an error has reached the patient. Instead, it implies that patient harm was avoided purely by chance, giving little credence to capture and recovery opportunities that may be working well or in need of improvement. 

Several respondents suggested that the term near miss is a confusing misnomer, and that a near miss is really a near “hit” or near “error.” A near “miss” is more applicable when trying to “hit” something, not avoid something. They suggested “close call” as a better term, and we agree. Although near miss appears to be well entrenched in healthcare terminology, we will try to refer to near misses as close calls when feasible in the future to prevent confusion (see Table 1).

Table 1. Definition of a Close Call (Near Miss)

Close call (near miss): An event, situation, or error that took place but was captured before reaching the patient. For example, penicillin was ordered for a patient allergic to the drug; however, the pharmacist was alerted to the allergy during computer order entry, the prescriber was called, and the penicillin was not dispensed or administered to the patient. Or the wrong drug was dispensed by pharmacy, and a nurse caught the error before it was administered to the patient.

 

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