Risk Management Department
Risk Management Department
What Causes Near-misses and How Are They Mitigated? Karen Gabel Speroni, PhD, MHSA, BSN, RN Judith Fisher, MSN, RN, NEA-BC Marie Dennis, MSN, RN, CENP, NEA-BC Marlon Daniel, MPH, MHS
Objectives: The objectives of this study were to determine the reasons hospital RNs attribute to near-misses and the techniques they used to mitigate these near-misses to prevent serious reportable events. Background: Our health system developed this definition for the study: A near-miss is a variation in a normal process that, if continued, could have a negative impact on patients. Methods: Study participants were RNs who completed a survey about a self-reported near-miss or another RN’s near-miss they’d witnessed. Data collected included participant demographics, near-miss occurrence by day of week and time, near-miss type, and attributed causes. Results: A total of 144 near-miss types were self-reported or witnessed by 123 respondents; of these, 43 (35%) self-reported a near-miss event and 80 (65%) witnessed a near-miss event. The respondents identified medication administration (19%) and transcription errors (10%) as the most frequent types of near-misses (N = 144). Selecting from 412 factors related to near-misses, more RNs attributed near-misses to personal factors than institutional factors. Top personal factors were not following policy and inappropriate decision making or critical assumptions. Top institutional factors were work-related interruptions and distractions, and poor communication about a patient. A total of 400 techniques were used to mitigate the nearmisses, nearly one per causative factor identified. Top techniques used were stop, think, act, review (STAR) and verification of proper procedures or actions. Conclusions: Hospital administrators should consider both personal and institutional factors when evaluating patientsafety programs. Education about mitigating techniques for near-misses is imperative for RNs.
At Inova Fair Oaks Hospital in Fairfax, Va., Karen Gabel Speroni is a nursing research scientist, Judith Fisher is the former director of clinical operations, Marie Dennis is the former chief nursing officer, and Marlon Daniel is a biostatistician. The authors thank the safety coaches, nursing leadership, research council, and librarians for their help with this study. Research Corner is coordinated by Cheryl Dumont, PhD, RN, CRNI, director of nursing research and the vascular access team at Winchester
LITERATURE REVIEW According to the Institute of Medicine’s To Err Is Human: Building a Safer Health System, healthcare providers need to better understand medical errors.1 The culture in hospitals has slowly changed over time. In the past, those committing errors may have been addressed individually by a manager and the error treated as an isolated incident. This culture didn’t support an environment of process improvement as a result of errors experienced. Hospital culture now has changed to one of transparency with a willingness to share information, learn from errors, and trend error types. This approach provides opportunities to study not only serious reportable events but also near-misses. The National Quality Forum (NQF) considers a serious reportable event to be preventable, serious, and either adverse, indicative of a problem in a healthcare setting’s safety systems, and/or important for public credibility or public accountability.2 According to the NQF, serious reportable events: • concern both the public and health-care professionals and providers • are clearly identifiable and measurable • are feasible to include in a reporting system • have a risk of occurrence that’s significantly influenced by health-care facility policies and procedures. When healthcare facilities develop methods of analyzing situations in which an error or poor patient outcome was avoided (a near-miss), future errors and adverse outcomes for patients can be prevented. The literature about near-misses focuses on increased reporting Medical Center in Winchester, Va. Dr. Dumont is also a member of the Nursing 2013 editorial board. The content in this article has received appropriate institutional review board and/or administrative approval for publication. The authors have disclosed that they have no fi nancial relationships related to this article. Reprinted with permission from Nursing, April 2013, pages 19-24.
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Risk Management Department by implementing cultural changes that promote sharing of safety-related information or developing automated reporting systems for both actual errors and near-misses.3-10 It also emphasizes medication errors and related near-misses.11-13 Research about what constitutes and contributes to near-misses and what’s needed to ensure safer processes of care has demonstrated that a near-miss is a constructive interruption in the pathway of error.14 Near-misses can lead to the development of processes and systems that enhance safety. Researchers have recommended identifying and testing near-miss variables and the mitigating mechanisms associated with processes of care. Research has also demonstrated that nurses are interrupted frequently; on average, 10 times per hour or every 6 minutes.15,16 Researchers classified interruptions as either other- or self-initiated, with other-initiated being the more frequently observed category (64%). Factors contributing to medication errors have been categorized as personal (not following policy and procedures, stress and tiredness, lack of knowledge of
medication) or institutional (distractions and interruptions, medication delivery systems, quality of prescriptions, heavy workload and multitasking, design of technology). Nurses administering high-risk medications reported interruptions as often as 14 times per hour, mostly by colleagues.17
STUDY PURPOSE We conducted survey research to determine the personal and institutional factors hospital RNs attribute to nearmisses and the techniques they used to mitigate the nearmisses so they didn’t result in serious reportable events.
METHODS Setting Our study was conducted in a 182-bed not-for-profit community hospital in the mid-Atlantic region that employs more than 600 RNs, 80% of them in full-time positions.
Near-misses by types* Self-report for near-miss by RN N = 43
Witnessed report for near-miss by another RN N = 80
Total N = 144
Medication administration
12 (27.91)
16 (20.00)
28 (19.44)
Transcription error
5 (11.63)
10 (12.50)
15 (10.42)
Noncompliance with policy/procedure
1 (2.33)
12 (15.00)
13 (9.03)
Order entry error
4 (9.30)
8 (10.00)
12 (8.33)
Patient identification
3 (6.98)
8 (10.00)
11 (7.64)
Incorrect physician orders
2 (4.65)
9 (11.25)
11 (7.64)
Incorrect procedure/process
4 (9.30)
4 (5.00)
8 (5.56)
Lack of communication among the care team or department team or to physician
1 (2.33)
6 (7.50)
7 (4.86)
Supplies/equipment
3 (6.98)
4 (5.00)
7 (4.86)
Patient monitoring
1 (2.33)
6 (7.50)
7 (4.86)
Lack of physician communication to the care team or department team
2 (4.65)
3 (3.75)
5 (3.47)
Verification against original physician order
1 (2.33)
3 (3.75)
4 (2.78)
0
4 (5.00)
4 (2.78)
Conflicting physician orders
1 (2.33)
2 (2.50)
3 (2.08)
Mislabeled specimen
2 (4.65)
1 (1.25)
3 (2.08)
No appropriate policy/procedure
2 (4.65)
0
2 (1.39)
Staff communication with patient/family
1 (2.33)
0
1 (0.69)
Patient consent/boarding pass
1 (2.33)
0
1 (0.69)
0
1 (1.25)
1 (0.69)
1(2.33)
0
1 (0.69)
Near-miss type, number (%)
Illegible physician orders
Hand-off/ticket to ride Other
*Near-miss type by self-report and witnessed report for 123 respondents (144 total types reported: self-reported, 47; witnessed, 97). Categories aren’t mutually exclusive.
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Risk Management Department Personal-related factors for near-misses* Self-report for near-miss by RN N = 43
Witnessed report for near-miss by another RN N = 80
Total N = 229
Didn’t follow policy
18 (41.86)
30 (37.50)
48 (20.96)
Inappropriate decisionmaking/critical thinking
11 (25.58)
26 (32.50)
37 (16.16)
Didn’t stop in the face of uncertainty
6 (13.95)
16 (20.00)
22 (9.61)
Personal factor, number (%)
Unfamiliar with policy content
3 (6.98)
7 (8.75)
10 (4.37)
Poor communication by self regarding patient to other RN, physician, or staff member
3 (6.98)
1 (1.25)
4 (1.75) 3 (1.31)
High stress level due to personal reasons
2 (4.65)
1 (1.25)
Working more than 40 hours/week in the last week at hospital and other hospital employment
1 (2.33)
0 1 (0.44)
*Personal related factors by self-report and witnessed report for 123 respondents (229 total personal factors reported: self-reported, 80; witnessed, 149). Categories aren’t mutually exclusive. †P < 0.05.
Study Design, Sample, and Procedures This was a prospective survey research study employing convenience sampling of hospital RNs. Safety coaches and nursing leadership distributed survey research packets to RNs. Safety coaches are staff members who’ve received additional education about peer checking and coaching and serve as unit safety leaders. RNs could participate in this study if they’d experienced a near-miss (self-reported occurrence) or if they’d witnessed a near-miss by another RN (witnessed occurrence) in our hospital. Each RN received a research packet containing the institutional review board-approved informed consent form, survey instrument (one for self-reporting and one for witnessed reporting), and an interoffice envelope addressed to the study investigator.
Survey Instrument Our hospital research council reviewed the survey instrument for content and clarity. The near-miss categories used in the survey instrument were based on the near-miss data reported through our hospital processes and the literature. The survey included this definition of a near-miss: a variation in a normal process that, if allowed to continue, could potentially have a negative impact on a patient. This was derived from the definition in The Joint Commission’s Comprehensive Accreditation Manual for Hospitals: “...any process variation that didn’t affect an outcome but for which a recurrence carries a significant chance of a serious adverse outcome.”18 Survey questions addressed participant demographics, time and day of week of near-misses, near-miss types, how personal and institutional factors (called related factors) were related to the near-miss (ranked as not related, somewhat related, related, very related, and unknown), and mitigating techniques used to prevent the near-miss 116
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from resulting in a serious reportable event. Researchers coded related factors as either personal (12 categories) or institutional (17 categories). Also, we considered the factor as related to the near-miss rankings if the respondent selected a ranking of somewhat related, related, or very related. Statistical analyses were completed using Statistical Analysis System software (version 9.1.3, Cary, N.C.).
RESULTS Of the 123 respondents, 43 (35%) surveys were from RNs who self-reported the near-miss, and 80 (65%) near-miss surveys were from RNs who witnessed the near-miss of another RN. Respondents were primarily full-time RNs with more than 15 years of RN experience. More part-time RNs provided witnessed reports (26%) than self-reports (7%) (P < 0.05). Near-misses occurred most often on Wednesdays (20%) between 1201 and 1800 hours (40%).
Near-miss Types Participants selected 144 (self-reported, 47; witnessed, 97) description categories of near-miss types for the 123 nearmisses reported in this study. (See Near-misses by types.) The most common types of near-misses were medication administration (overall, 20%: self-reported, 28%; witnessed, 20%) and transcription errors (overall, 10%: self-reported, 12%; witnessed, 13%).
Near-miss Related Factors Overall, RNs attributed 412 related factors to the near-misses (personal factors, 229; institutional factors, 183). The most frequently reported personal factors were not following policy (overall, 21%: self-reported, 42%; witnessed, 38%), and inappropriate decision making or critical thinking Volume 34 Number 3 July–September 2014
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Risk Management Department (overall, 16%: self-reported, 26%; witnessed, 33%). (See Personal-related factors for near-misses.) The most frequently cited institution-related factors were work-related interruptions or distractions (overall, 18%: self-reported, 37%; witnessed, 21%) and poor communication about the patient by other RNs, physicians, or staff members (overall, 14%: self-reported, 14%; witnessed, 24%). (See Institutional-related factors for near-misses.)
Near-miss Mitigating Techniques Nearly as many mitigating techniques (400) were used by the RNs to stop the near-misses as were factors attributed to the near-misses (412). (See Mitigating factor techniques used for near-misses.) Of the mitigating techniques used, 147 were self-reported and 253 were witnessed. The most common technique used was based on the acronym STAR (overall, 18%: self-reported and witnessed, 58%): • Stop to concentrate on the task. • Think about the task.
• Act to accomplish the task. • Review how well the task was accomplished.19 After STAR, the most common technique used was verification of the proper procedure or actions (overall, 15%: self-reported, 56%; witnessed, 43%).19
DISCUSSION Consistent with the literature, our survey research found work-related interruptions and distractions to be the primary institutional factor (18%) that RNs attribute to nearmisses. Although personal interruptions also occurred, they weren’t a primary reason for near-misses. RNs used about one mitigating technique for each related factor to stop the near-miss from resulting in a serious reportable event. As a result of this research, at our hospital we continued to recommend that nurses use the STAR technique when interrupted. We also reinforced the idea that nurses don’t have to answer the telephone if it rings during tasks requiring critical thinking, such as medication administration.
Institutional-related factors for near-misses* Self-report for near-miss by RN N = 43
Witnessed report for near-miss by another RN N = 80
Total N = 183
Work-related interruptions/distractions
16 (37.21)
17 (21.25)
33 (18.03)
Poor communication regarding patient by other RN, physician, or staff member
6 (13.95)
19 (23.75)
25 (13.66)
Lack of policy/procedure to guide
9 (20.93)
9 (11.25)
18 (9.84)
High stress level due to work environment
8 (18.60)
9 (11.25)
17 (9.29)
Lack of training
2 (4.65)
14 (17.50)
16 (8.74)
Patient high acuity level
8 (18.60)
6 (7.50)
14 (7.65)
Lack of knowledge on how to use equipment
3 (6.98)
10 (12.50)
13 (7.10)
Lack of competency
2 (4.65)
9 (11.25)
11 (6.01)
Institutional factors, number (%)
†
Other
7 (16.28)
2 (2.50)
9 (4.92)
Unaware policy exists
1 (2.33)
6 (7.50)
7 (3.83)
Inadequate equipment
3 (6.98)
3 (3.75)
6 (3.28)
Inadequate staffing
3 (6.98)
1 (1.25)
4 (2.19)
RN(s) unfamiliar with unit
3 (6.98)
1 (1.25)
4 (2.19)
Unavailable equipment
1 (2.33)
2 (2.50)
3 (1.64)
Working more than 40 hours/week in the last week at hospital
1 (2.33)
0
1 (0.55)
Overtime for the specific shift during which the near-miss occurred
1 (2.33)
0
1 (0.55)
Equipment malfunction
1(2.33)
0
1 (0.55)
*Institutional-related factors by self-report and witnessed report for the 123 respondents (183 total institutional factors reported: self-reported, 75; witnessed, 108). Categories aren’t mutually exclusive. †P < 0.05.
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Risk Management Department Mitigating factor techniques used for near-misses* Self-report for near-miss by RN N=43
Witnessed report for near-miss by RN N = 80
Total N = 400
Use of stop, think, act, review (STAR)
25 (58.14)
46 (57.50)
71 (17.75)
Verification of the proper procedure or actions
24 (55.81)
34 (42.50)
58 (14.50)
Proper patient identification
17 (39.53)
25 (31.25)
42 (10.50)
Clarifying questions
10 (23.26)
23 (28.75)
33 (8.25)
Technique, number (%)
*Mitigating factor techniques used by self-report and witnessed report for 123 respondents (400 total mitigating techniques reported: self-reported, 147; witnessed, 253). Categories aren’t mutually exclusive.
Our research supports the recommendation that RNs should continue to be educated about safety programs that employ mitigating techniques. Because inappropriate decision making and critical thinking was the second most common personal factor (16%) attributed to causing near-misses, educating RNs about this topic is also warranted. Because poor communication was the second most common institutional factor (14%) contributing to near-misses, we suggest providing education to improve RNs’ communication with other healthcare providers. Research on the effect of quiet areas where nurses can concentrate on aspects of their work requiring critical thinking skills, such as medication administration, is also warranted.
Limitations of the Research In our study, participants could provide survey responses either by self-reporting or witnessing a near-miss by another nurse. To protect confidentiality, we didn’t collect names, so it isn’t known whether a participant completed more than one survey. Another limitation of this study is that perceptions of the RN witnessing the near-miss may or may not be the same as the RN experiencing the near-miss. In addition, our study employed a convenience sample design that let participants self-select, another limitation. Those who experienced near-misses and didn’t participate in this study may have experienced different types of near-misses and may have attributed related factors differently.
CONCLUSIONS Recommendations are twofold. First, hospital administrators should consider both personal and institutional factors when evaluating patient-safety programs. Identifying these factors is a first step in evaluating how existing safety programs can be improved. Institutional factors may be easier to improve than personal factors.
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Second, educational programs for RNs about how to use mitigating techniques for near-misses, such as STAR, are imperative to prevent near-misses from resulting in serious reportable events. REFERENCES
1. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000. 2. National Quality Forum. Serious reportable events in healthcare 2011. 2011. http://www.qualityforum.org/Publications/2011/12/ Serious_Reportable_Events_in_Healthcare_2011.aspx. 3. Conerly, C. Strategies to increase reporting of near-misses and adverse events. J Nurs Care Qual. 2007;22(2):102-106. 4. Jones, KJ, Cochran, G, Hicks, RW, Mueller, KJ. Translating research into practice: voluntary reporting of medication errors in critical access hospitals. J Rural Health. 2004;20(4):335-343. 5. Killen, AR, Beyea, SC. Learning from near misses in an effort to promote patient safety. AORN J. 2003;77(2):423-425. 6. Morath, J, Leary, M. Creating safe spaces in organizations to talk about safety. Nurs Econ. 2004;22(6):344-351, 354. 7. Paparella, S. A safe haven for nurses to report medication errors? Clarian and Spectrum Health Systems prove it is possible! J Emerg Nurs. 2005;31(4):373-375. 8. Simpson, RL. Error reporting as a preventive force. Nurs Manage. 2005;36(6):21-24, 56. 9. Suresh, G, Horbar, JD, Plsek, P, et al. Voluntary anonymous reporting of medical errors for neonatal intensive care. Pediatrics. 2004;113(6):1609-1618. 10. American Nurses Association. News Release. Medication errors and syringe safety are top concerns for nurses according to new national study. 2007. http://www.nursingworld.org/ FunctionalMenuCategories/MediaResources/PressReleases/2007/ SyringeSafetyStudy.pdf. 11. Mayo, AM, Duncan, D. Nurse perceptions of medication errors: what we need to know for patient safety. J Nurs Care Qual. 2004;19(3):209-217. 12. Reid-Searl, K, Moxham, L, Happell, B. Enhancing patient safety: the importance of direct supervision for avoiding medication errors and near misses by undergraduate nursing students. Int J Nurs Pract. 2010;16(3):225-232. 13. Ulanimo, VM, O’Leary-Kelley, C, Connolly, PM. Nurses’ perceptions of causes of medication errors and barriers to reporting. J Nurs Care Qual. 2007;22(1):28-33. 14. Jeffs, L, Affonso, DD, Macmillan, K. Near misses: paradoxical realities in everyday clinical practice. Int J Nurs Pract. 2008;14(6):486-494.
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Risk Management Department 15. Kalisch, BJ, Aebersold, M. Interruptions and multitasking in nursing care. Jt Comm J Qual Patient Saf. 2010;36(3): 126-132. 16. O’Neil, S, Speroni, KG, Dugan, L, Daniel, MG. A 2-tier study of direct care providers assessing the effectiveness of the red rule education project and precipitating factors surrounding red rule violations. Qual Manag Health Care. 2010;19(3):259-264.
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17. Trbovich, P, Prakash, V, Stewart, J, Trip, K, Savage, P. Interruptions during the delivery of high-risk medications. J Nurs Adm. 2010;40(5):211-218. 18. The Joint Commission. Comprehensive Accreditation Manual for Hospitals. 2011. 19. Kenney, C. The Best Practice: How the New Quality Movement Is Transforming Medicine. New York, NY: PublicAffairs; 2008.
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Risk Management Department
What Causes Near-misses and How Are They Mitigated? Karen Gabel Speroni, PhD, MHSA, BSN, RN Judith Fisher, MSN, RN, NEA-BC Marie Dennis, MSN, RN, CENP, NEA-BC Marlon Daniel, MPH, MHS
Objectives: The objectives of this study were to determine the reasons hospital RNs attribute to near-misses and the techniques they used to mitigate these near-misses to prevent serious reportable events. Background: Our health system developed this definition for the study: A near-miss is a variation in a normal process that, if continued, could have a negative impact on patients. Methods: Study participants were RNs who completed a survey about a self-reported near-miss or another RN’s near-miss they’d witnessed. Data collected included participant demographics, near-miss occurrence by day of week and time, near-miss type, and attributed causes. Results: A total of 144 near-miss types were self-reported or witnessed by 123 respondents; of these, 43 (35%) self-reported a near-miss event and 80 (65%) witnessed a near-miss event. The respondents identified medication administration (19%) and transcription errors (10%) as the most frequent types of near-misses (N = 144). Selecting from 412 factors related to near-misses, more RNs attributed near-misses to personal factors than institutional factors. Top personal factors were not following policy and inappropriate decision making or critical assumptions. Top institutional factors were work-related interruptions and distractions, and poor communication about a patient. A total of 400 techniques were used to mitigate the nearmisses, nearly one per causative factor identified. Top techniques used were stop, think, act, review (STAR) and verification of proper procedures or actions. Conclusions: Hospital administrators should consider both personal and institutional factors when evaluating patientsafety programs. Education about mitigating techniques for near-misses is imperative for RNs.
At Inova Fair Oaks Hospital in Fairfax, Va., Karen Gabel Speroni is a nursing research scientist, Judith Fisher is the former director of clinical operations, Marie Dennis is the former chief nursing officer, and Marlon Daniel is a biostatistician. The authors thank the safety coaches, nursing leadership, research council, and librarians for their help with this study. Research Corner is coordinated by Cheryl Dumont, PhD, RN, CRNI, director of nursing research and the vascular access team at Winchester
LITERATURE REVIEW According to the Institute of Medicine’s To Err Is Human: Building a Safer Health System, healthcare providers need to better understand medical errors.1 The culture in hospitals has slowly changed over time. In the past, those committing errors may have been addressed individually by a manager and the error treated as an isolated incident. This culture didn’t support an environment of process improvement as a result of errors experienced. Hospital culture now has changed to one of transparency with a willingness to share information, learn from errors, and trend error types. This approach provides opportunities to study not only serious reportable events but also near-misses. The National Quality Forum (NQF) considers a serious reportable event to be preventable, serious, and either adverse, indicative of a problem in a healthcare setting’s safety systems, and/or important for public credibility or public accountability.2 According to the NQF, serious reportable events: • concern both the public and health-care professionals and providers • are clearly identifiable and measurable • are feasible to include in a reporting system • have a risk of occurrence that’s significantly influenced by health-care facility policies and procedures. When healthcare facilities develop methods of analyzing situations in which an error or poor patient outcome was avoided (a near-miss), future errors and adverse outcomes for patients can be prevented. The literature about near-misses focuses on increased reporting Medical Center in Winchester, Va. Dr. Dumont is also a member of the Nursing 2013 editorial board. The content in this article has received appropriate institutional review board and/or administrative approval for publication. The authors have disclosed that they have no fi nancial relationships related to this article. Reprinted with permission from Nursing, April 2013, pages 19-24.
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Risk Management Department by implementing cultural changes that promote sharing of safety-related information or developing automated reporting systems for both actual errors and near-misses.3-10 It also emphasizes medication errors and related near-misses.11-13 Research about what constitutes and contributes to near-misses and what’s needed to ensure safer processes of care has demonstrated that a near-miss is a constructive interruption in the pathway of error.14 Near-misses can lead to the development of processes and systems that enhance safety. Researchers have recommended identifying and testing near-miss variables and the mitigating mechanisms associated with processes of care. Research has also demonstrated that nurses are interrupted frequently; on average, 10 times per hour or every 6 minutes.15,16 Researchers classified interruptions as either other- or self-initiated, with other-initiated being the more frequently observed category (64%). Factors contributing to medication errors have been categorized as personal (not following policy and procedures, stress and tiredness, lack of knowledge of
medication) or institutional (distractions and interruptions, medication delivery systems, quality of prescriptions, heavy workload and multitasking, design of technology). Nurses administering high-risk medications reported interruptions as often as 14 times per hour, mostly by colleagues.17
STUDY PURPOSE We conducted survey research to determine the personal and institutional factors hospital RNs attribute to nearmisses and the techniques they used to mitigate the nearmisses so they didn’t result in serious reportable events.
METHODS Setting Our study was conducted in a 182-bed not-for-profit community hospital in the mid-Atlantic region that employs more than 600 RNs, 80% of them in full-time positions.
Near-misses by types* Self-report for near-miss by RN N = 43
Witnessed report for near-miss by another RN N = 80
Total N = 144
Medication administration
12 (27.91)
16 (20.00)
28 (19.44)
Transcription error
5 (11.63)
10 (12.50)
15 (10.42)
Noncompliance with policy/procedure
1 (2.33)
12 (15.00)
13 (9.03)
Order entry error
4 (9.30)
8 (10.00)
12 (8.33)
Patient identification
3 (6.98)
8 (10.00)
11 (7.64)
Incorrect physician orders
2 (4.65)
9 (11.25)
11 (7.64)
Incorrect procedure/process
4 (9.30)
4 (5.00)
8 (5.56)
Lack of communication among the care team or department team or to physician
1 (2.33)
6 (7.50)
7 (4.86)
Supplies/equipment
3 (6.98)
4 (5.00)
7 (4.86)
Patient monitoring
1 (2.33)
6 (7.50)
7 (4.86)
Lack of physician communication to the care team or department team
2 (4.65)
3 (3.75)
5 (3.47)
Verification against original physician order
1 (2.33)
3 (3.75)
4 (2.78)
0
4 (5.00)
4 (2.78)
Conflicting physician orders
1 (2.33)
2 (2.50)
3 (2.08)
Mislabeled specimen
2 (4.65)
1 (1.25)
3 (2.08)
No appropriate policy/procedure
2 (4.65)
0
2 (1.39)
Staff communication with patient/family
1 (2.33)
0
1 (0.69)
Patient consent/boarding pass
1 (2.33)
0
1 (0.69)
0
1 (1.25)
1 (0.69)
1(2.33)
0
1 (0.69)
Near-miss type, number (%)
Illegible physician orders
Hand-off/ticket to ride Other
*Near-miss type by self-report and witnessed report for 123 respondents (144 total types reported: self-reported, 47; witnessed, 97). Categories aren’t mutually exclusive.
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Risk Management Department Personal-related factors for near-misses* Self-report for near-miss by RN N = 43
Witnessed report for near-miss by another RN N = 80
Total N = 229
Didn’t follow policy
18 (41.86)
30 (37.50)
48 (20.96)
Inappropriate decisionmaking/critical thinking
11 (25.58)
26 (32.50)
37 (16.16)
Didn’t stop in the face of uncertainty
6 (13.95)
16 (20.00)
22 (9.61)
Personal factor, number (%)
Unfamiliar with policy content
3 (6.98)
7 (8.75)
10 (4.37)
Poor communication by self regarding patient to other RN, physician, or staff member
3 (6.98)
1 (1.25)
4 (1.75) 3 (1.31)
High stress level due to personal reasons
2 (4.65)
1 (1.25)
Working more than 40 hours/week in the last week at hospital and other hospital employment
1 (2.33)
0 1 (0.44)
*Personal related factors by self-report and witnessed report for 123 respondents (229 total personal factors reported: self-reported, 80; witnessed, 149). Categories aren’t mutually exclusive. †P < 0.05.
Study Design, Sample, and Procedures This was a prospective survey research study employing convenience sampling of hospital RNs. Safety coaches and nursing leadership distributed survey research packets to RNs. Safety coaches are staff members who’ve received additional education about peer checking and coaching and serve as unit safety leaders. RNs could participate in this study if they’d experienced a near-miss (self-reported occurrence) or if they’d witnessed a near-miss by another RN (witnessed occurrence) in our hospital. Each RN received a research packet containing the institutional review board-approved informed consent form, survey instrument (one for self-reporting and one for witnessed reporting), and an interoffice envelope addressed to the study investigator.
Survey Instrument Our hospital research council reviewed the survey instrument for content and clarity. The near-miss categories used in the survey instrument were based on the near-miss data reported through our hospital processes and the literature. The survey included this definition of a near-miss: a variation in a normal process that, if allowed to continue, could potentially have a negative impact on a patient. This was derived from the definition in The Joint Commission’s Comprehensive Accreditation Manual for Hospitals: “...any process variation that didn’t affect an outcome but for which a recurrence carries a significant chance of a serious adverse outcome.”18 Survey questions addressed participant demographics, time and day of week of near-misses, near-miss types, how personal and institutional factors (called related factors) were related to the near-miss (ranked as not related, somewhat related, related, very related, and unknown), and mitigating techniques used to prevent the near-miss 116
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from resulting in a serious reportable event. Researchers coded related factors as either personal (12 categories) or institutional (17 categories). Also, we considered the factor as related to the near-miss rankings if the respondent selected a ranking of somewhat related, related, or very related. Statistical analyses were completed using Statistical Analysis System software (version 9.1.3, Cary, N.C.).
RESULTS Of the 123 respondents, 43 (35%) surveys were from RNs who self-reported the near-miss, and 80 (65%) near-miss surveys were from RNs who witnessed the near-miss of another RN. Respondents were primarily full-time RNs with more than 15 years of RN experience. More part-time RNs provided witnessed reports (26%) than self-reports (7%) (P < 0.05). Near-misses occurred most often on Wednesdays (20%) between 1201 and 1800 hours (40%).
Near-miss Types Participants selected 144 (self-reported, 47; witnessed, 97) description categories of near-miss types for the 123 nearmisses reported in this study. (See Near-misses by types.) The most common types of near-misses were medication administration (overall, 20%: self-reported, 28%; witnessed, 20%) and transcription errors (overall, 10%: self-reported, 12%; witnessed, 13%).
Near-miss Related Factors Overall, RNs attributed 412 related factors to the near-misses (personal factors, 229; institutional factors, 183). The most frequently reported personal factors were not following policy (overall, 21%: self-reported, 42%; witnessed, 38%), and inappropriate decision making or critical thinking Volume 34 Number 3 July–September 2014
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Risk Management Department (overall, 16%: self-reported, 26%; witnessed, 33%). (See Personal-related factors for near-misses.) The most frequently cited institution-related factors were work-related interruptions or distractions (overall, 18%: self-reported, 37%; witnessed, 21%) and poor communication about the patient by other RNs, physicians, or staff members (overall, 14%: self-reported, 14%; witnessed, 24%). (See Institutional-related factors for near-misses.)
Near-miss Mitigating Techniques Nearly as many mitigating techniques (400) were used by the RNs to stop the near-misses as were factors attributed to the near-misses (412). (See Mitigating factor techniques used for near-misses.) Of the mitigating techniques used, 147 were self-reported and 253 were witnessed. The most common technique used was based on the acronym STAR (overall, 18%: self-reported and witnessed, 58%): • Stop to concentrate on the task. • Think about the task.
• Act to accomplish the task. • Review how well the task was accomplished.19 After STAR, the most common technique used was verification of the proper procedure or actions (overall, 15%: self-reported, 56%; witnessed, 43%).19
DISCUSSION Consistent with the literature, our survey research found work-related interruptions and distractions to be the primary institutional factor (18%) that RNs attribute to nearmisses. Although personal interruptions also occurred, they weren’t a primary reason for near-misses. RNs used about one mitigating technique for each related factor to stop the near-miss from resulting in a serious reportable event. As a result of this research, at our hospital we continued to recommend that nurses use the STAR technique when interrupted. We also reinforced the idea that nurses don’t have to answer the telephone if it rings during tasks requiring critical thinking, such as medication administration.
Institutional-related factors for near-misses* Self-report for near-miss by RN N = 43
Witnessed report for near-miss by another RN N = 80
Total N = 183
Work-related interruptions/distractions
16 (37.21)
17 (21.25)
33 (18.03)
Poor communication regarding patient by other RN, physician, or staff member
6 (13.95)
19 (23.75)
25 (13.66)
Lack of policy/procedure to guide
9 (20.93)
9 (11.25)
18 (9.84)
High stress level due to work environment
8 (18.60)
9 (11.25)
17 (9.29)
Lack of training
2 (4.65)
14 (17.50)
16 (8.74)
Patient high acuity level
8 (18.60)
6 (7.50)
14 (7.65)
Lack of knowledge on how to use equipment
3 (6.98)
10 (12.50)
13 (7.10)
Lack of competency
2 (4.65)
9 (11.25)
11 (6.01)
Institutional factors, number (%)
†
Other
7 (16.28)
2 (2.50)
9 (4.92)
Unaware policy exists
1 (2.33)
6 (7.50)
7 (3.83)
Inadequate equipment
3 (6.98)
3 (3.75)
6 (3.28)
Inadequate staffing
3 (6.98)
1 (1.25)
4 (2.19)
RN(s) unfamiliar with unit
3 (6.98)
1 (1.25)
4 (2.19)
Unavailable equipment
1 (2.33)
2 (2.50)
3 (1.64)
Working more than 40 hours/week in the last week at hospital
1 (2.33)
0
1 (0.55)
Overtime for the specific shift during which the near-miss occurred
1 (2.33)
0
1 (0.55)
Equipment malfunction
1(2.33)
0
1 (0.55)
*Institutional-related factors by self-report and witnessed report for the 123 respondents (183 total institutional factors reported: self-reported, 75; witnessed, 108). Categories aren’t mutually exclusive. †P < 0.05.
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Risk Management Department Mitigating factor techniques used for near-misses* Self-report for near-miss by RN N=43
Witnessed report for near-miss by RN N = 80
Total N = 400
Use of stop, think, act, review (STAR)
25 (58.14)
46 (57.50)
71 (17.75)
Verification of the proper procedure or actions
24 (55.81)
34 (42.50)
58 (14.50)
Proper patient identification
17 (39.53)
25 (31.25)
42 (10.50)
Clarifying questions
10 (23.26)
23 (28.75)
33 (8.25)
Technique, number (%)
*Mitigating factor techniques used by self-report and witnessed report for 123 respondents (400 total mitigating techniques reported: self-reported, 147; witnessed, 253). Categories aren’t mutually exclusive.
Our research supports the recommendation that RNs should continue to be educated about safety programs that employ mitigating techniques. Because inappropriate decision making and critical thinking was the second most common personal factor (16%) attributed to causing near-misses, educating RNs about this topic is also warranted. Because poor communication was the second most common institutional factor (14%) contributing to near-misses, we suggest providing education to improve RNs’ communication with other healthcare providers. Research on the effect of quiet areas where nurses can concentrate on aspects of their work requiring critical thinking skills, such as medication administration, is also warranted.
Limitations of the Research In our study, participants could provide survey responses either by self-reporting or witnessing a near-miss by another nurse. To protect confidentiality, we didn’t collect names, so it isn’t known whether a participant completed more than one survey. Another limitation of this study is that perceptions of the RN witnessing the near-miss may or may not be the same as the RN experiencing the near-miss. In addition, our study employed a convenience sample design that let participants self-select, another limitation. Those who experienced near-misses and didn’t participate in this study may have experienced different types of near-misses and may have attributed related factors differently.
CONCLUSIONS Recommendations are twofold. First, hospital administrators should consider both personal and institutional factors when evaluating patient-safety programs. Identifying these factors is a first step in evaluating how existing safety programs can be improved. Institutional factors may be easier to improve than personal factors.
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Second, educational programs for RNs about how to use mitigating techniques for near-misses, such as STAR, are imperative to prevent near-misses from resulting in serious reportable events. REFERENCES
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Risk Management Department 15. Kalisch, BJ, Aebersold, M. Interruptions and multitasking in nursing care. Jt Comm J Qual Patient Saf. 2010;36(3): 126-132. 16. O’Neil, S, Speroni, KG, Dugan, L, Daniel, MG. A 2-tier study of direct care providers assessing the effectiveness of the red rule education project and precipitating factors surrounding red rule violations. Qual Manag Health Care. 2010;19(3):259-264.
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17. Trbovich, P, Prakash, V, Stewart, J, Trip, K, Savage, P. Interruptions during the delivery of high-risk medications. J Nurs Adm. 2010;40(5):211-218. 18. The Joint Commission. Comprehensive Accreditation Manual for Hospitals. 2011. 19. Kenney, C. The Best Practice: How the New Quality Movement Is Transforming Medicine. New York, NY: PublicAffairs; 2008.
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