Jany’s near miss is just among many cases encountered in care provision units.The case reveals numerous errors, which occurred at diverse levels. At the patient level, Jany failed to observe her treatment. She was ready to inject herself even without reading the boxes. She failed to distinguish between the atropine and LMWH. While she could have carried the atropine accidentally, she should have noted she had two boxes and read or called the pharmacist earlier. There were failures at the provider level too. The RN and the physician could not maintain the patient's INR within the therapeutic range. The nursing staff failed to remove the atropine syringe from Jany’s bedside when it was apparent that the medicine was no longer needed. The pharmacist was adamant to the patient dissatisfaction with the discharge instructions. She went ahead to discharge her even with the doubts. The system also failed, placing medicines at the patient’s bedside with no proper instruction was unexpected. The manufactures as well cannot be spared. The packaging design and decision for atropine and LMWH syringes was wrong. There should be no situation where two medicines are either packed in similar looking boxes or syringe designs.
The only fortunate thing is that amid the errors, Jany was not harmed. This could have amounted to a case of negligence. Jany’s case is a perfect near miss. Near misses are unexpected and unsafe acts have high potential of harming patient but do not. The determination of a snear miss-ness is based on two key concepts: whether the incident was the patient’s reach and whether harm happened. When the two concepts are put together, the result is: (i) the harmful incidents did not reach the patient, (ii) the harmful incidents reached the patient but no harm resulted, or (iii) harm was caused because the incident reached the patient (Pham, Kim, Natterman, 2010). These incidents act as quality care indicators.
Some scholars prefer referring to near misses as close calls. Close call concept allow for the determination of those incidences that actually reached the patient. Based on the understanding: (i) the harmful incidents did not reach the patient, (ii) the harmful incidents reached the patient but no harm resulted are considered close calls; and iii) harm was caused because the incident reached the patient. is a "hit". According to Wu AW, ed (2011), Jany’s scenario can be described as a near miss because it presents a "an event or a situation that did not produce patient harm because it did not reach the patient, either due to chance or to capture before reaching the patient; or if it did reach the patient, due to robustness of the patient or to timely "(Wu AW, ed, 2011, n.d). Notably, some errors result harm among patients, while others fail. Close calls, or near misses hardly cause any harm.
Near Misses Frequency and Relativeness to medical Errors.
The frequency of near misses and their relativeness to medical errors proves difficult to establish with lots of accuracy. The main challenge is the lack of systematic errors capturing mechanisms. However, estimated reveal that for every preventable death, there occur between 7 and 100 close calls that occur before the mortality (Pham, Kim, Natterman, 2010). It is certain that near misses have high reporting rate as compared to adverse events. Statistics from the Pennsylvania Patient Safety Reporting System that analyzed over 200,000 reports annually, established that 97% of them were close calls (Pham, Kim, Natterman, 2010). Often, nurse use safety pyramid to demonstrate the medical occurrences: at the base of the pyramid are the errors, at the center calls, and incidences that can cause harm at the top.
Quality Improvement Measures
Identification of Near Misses
In any healthcare setting quality improvement measures starts with problem identification before change is initiated. There are many potential ways of identifying missed calls. Commonly, direct reporting has been the most applied method in many healthcare setting. Direct reporting method often used is clinical monitoring. Patient safety reporting systems are important quality improvement strategies. Incident reports allow organization manages roll our quality determination models such as Ishakawa cause and effect diagram.
Frontline care workers can report incidence in various ways. One strategy can be the use of paper based model where reports are documented. Calls can be made directly to report incidence to the relevant authorities. Other methods include email reporting, online reporting, paging, and recorded hotline based on the observations. On the other hand, patients and families can also report near miss incidents (Institute of Medicine, 2004). While online reporting strategies are considered fast and reliable, the best reporting strategy depends on the organization.
The rates at which near misses occur is believed to be significantly high for capturing. As a result, organizations only struggle to capture a fraction of these events. Since even a small data can be vital for change creation.
Importantly for institutions, it is not necessary to capture every incident or every near miss that occurs. Given that the true prevalence of near misses is likely quite high, capturing even a fraction of these can allow robust analysis (Millman, Pronovost, Makary, & Wu, 2011). In fact, capturing every adverse event or near miss can be overwhelming and may be undesirable, as in the case of repeated reporting of the same incident.
Active clinical monitoring occurs when data collection process is built on the clinical process. For example, anesthesiologists in operating room can chart vital signs. Consequently, pharmacy systematic recording can capture erroneously prescribed medications (Institute of Medicine, 2004). In some cases checklist can be completed before placement of central venous catheter and added to the medical records. Such monitoring strategies can ensure accurate information is collected and put to practice. The information captured during care procedures can be used to underscore the cause of clinical miss and change strategies developed.
To ensure quality improve in cases such as those of Jany, the situation should be recorded or identified, properly analyzed, and new strategies implemented. First, Jany’s incident should be properly documented and reported for aggregate and individual examination (Wu, 2011). The pharmacist should document and report the case to the organizations patient safety reporting system.
Reporting should be followed by detailed investigation over the incident. The case information should be collected from all the front healthcare providers: the ED physician, the ED nurse, the RNs, and the pharmacist ((Millman, Pronovost, Makary, & Wu, 2011)). Investigation should further involve questioning the patient and her family, while sometimes deemed unnecessary, questioning can generate more information on the issue (Millman, Pronovost, Makary, & Wu, 2011). The as well should focus on identification of common, recurring, and systematic errors, or hazards which can be handled. Investigators should identify conditions for amelioration. In Jany’s case, the mitigating factor would be the lack atropine syringe’s needle that made it difficult for the patient to self-inject.
Patient safety committee, or/and other management team should be involved to discuss the incident and the result from the analysis. The discussion should be assigned action priority depending on the frequency and harm perceived. In case the miss incident occurs often and present high probability of causing harm, it should be given high priority. Solutions should hence be proposed to minimize such occurrences (Wu, 2011). Project charter should be developed with full elaboration of the project scope and task assignments. In the case of Jany, the patient safety committee could come up with three proposals. First, the therapeutic and pharmacy committee should be charged with altering the ordering template for all bedside medications and should include discontinuation time (Wu, Lipshutz, & Pronovost, 2008). Second, ED nursing director should modify standard procedures for discharges. All medications should be packed by or with the supervision of a nurse. Finally, the pharmacy should introduce warning label for all injectable cardioactive medications, and other related medicines. The recommendations should be implemented with constant follow-ups and evaluations to determine their effectiveness.
Near Miss is a common medical administration problem. Jany’s case is an example of the challenges as they occur in everyday nursing environment. To manage the near miss and medical error challenges, the care providers should ensure a comprehensive data capturing and documentation. The captured data should be analyzed and utilized to create new change. Care providers can as well identify recovery strategies that can be incorporated in development of a care processes. Nevertheless, close calls have no much distinction from adverse events. Both close calls and adverse events are free lessons on the manner with which medical approaches go wrong before a patient is hurt and an intervention strategy developed.
Institute of Medicine. (2004). Patient Safety: Achieving a New Standard for Care. Washington, DC: National Academies Press.
Marella, W. (2007). Why worry about near misses? Patient Saf Qual Healthc, 4:22-26.
Millman, E., Pronovost, P., Makary, M., & Wu, A. (2011). Patient-assisted incident reporting: including the patient in patient safety. J Patient Saf, 7:106-108.
Pham, J., Kim, G., & Natterman, J., et al. (2010). ReCASTing the RCA: an improved model for performing root cause analyses. Am J Med Qual. 25:186-191.
Wu, A. (2011). The Value of Close Calls in Improving Patient Safety. Oakbrook Terrace, IL: Joint Commission Resources.
Wu, A., Lipshutz, A., & Pronovost, P. (2008). Effectiveness and efficiency of root cause analysis in medicine. JAMA, 299:685-687.