The Near Miss
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This article appears in the December 2012 issue of HealthLeaders magazine.
Reporting and analyzing every error that almost harmed a patient may be an expensive hassle. But for Paula Holbrook, RN, BHS, JD, CPHRM, associate director of risk management and clinical risk manager for the University of Kentucky Healthcare's A.B. Chandler Medical Center, it's just as valuable for preventing harm as reviewing those mistakes that did hurt patients.
Holbrook and her team want to capture the "near misses, the little things that don't reach the patient," she says. "They signal the need for change because of a potentially or actively defective process." Near misses happen more frequently, and thus are goldmines for process improvement.
Here's one example, she says. "A patient with the same last name as another patient is taken to the operating room and is nearly at the point of anesthesia induction when someone reports, 'Hey, we took the wrong patient.'
"It didn't result in harm, but we want to know how this happened, and as soon as I got the call, we mobilized people and analyzed it quickly. It gives us an opportunity to intervene early and prevent these hazards—even small ones—from becoming losses. You want to get this before you have that 'Oh my God' moment.' "
In this case, Common Formats, an electronic tool developed by the Agency for Healthcare Research and Quality, helped Holbrook and her team identify failure points in communication and "the breach of the patient identification process at several points that didn't stop the line until it got nearly to the point where we put the patient to sleep. That was a big deal to us."
The 600-bed hospital is working with its patient safety organizations to use Common Formats, a taxonomic decision tree that allows providers to categorize each such event in one of three buckets—near misses, unsafe conditions, or actual patient harm incidents—and then drill down to what might have led to the circumstance and where it occurred.
Nine types of events are captured, including those involving blood products; devices, medical or surgical supplies, and health information technology; falls; healthcare-associated infections; medications; perinatal care; pressure ulcers; surgery or anesthesia; and venous thromboembolism.
The system also grades the level of harm to a patient, visitor, or staff member, as to whether it caused death, severe permanent harm, permanent harm, or temporary harm; required additional treatment; caused emotional distress or inconvenience; or did not cause harm.
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