Near-miss analysis in a large hospital in southern Brazil: A 5-year retrospective study

Analyzing near-miss incidents provides an opportunity to improve processes and routines, developing safer practices by detecting and preventing situations that can cause serious harm. However, little is known about how health care professionals perceive the reporting and analysis of near-miss incidents in their daily practice [15–17]. There is also evidence that professionals tend to correct near-miss incidents as soon as they are perceived (quick fixes) without further action – which is a loss in terms of organizational learning [15–18]. This explains, at least to a certain extent, the scarcity of Brazilian publications on this theme.

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Fig. 4.

Absolute number of near miss incidents according to occupation.

Our study describes the type and frequency of near-miss incidents reported in a large Brazilian hospital. The steady growth in the number of events reported since implementation of the reporting system shows a trend, which is an expected effect of the visual method used to encourage the reporting of near misses. According to the literature, incident reporting can be a powerful tool for developing and maintaining risk awareness in health care practice [19]. Increased incident reporting may be a result of organizational efforts to develop a culture of safety. Indeed, our results agree with a National Health System Report that the number of incidents reported to the National Reporting and Learning System has continued to increase since the incident report system was implemented in October 2003 [20]. Previous experience from other industries has shown that as an organizational culture matures, the staff become more likely to report incidents. Thus, an increase in incident reporting should not be understood as an indication of patient safety failures, but rather of increased awareness of safety issues among workers and a sign of a more open and transparent organizational culture [20,21]. In other words, staff adherence to reporting tools and processes depends directly on how familiar they are with such processes, their acceptance of best safety practices, and on how comfortable they feel with reporting incidents [22,23]. The results we describe reflect HMV’s efforts to advance organizational learning. HMV was the first hospital in southern Brazil to be accredited by the Joint Commission International (2002).

The most frequent type of near-miss incident observed in this study involved medication processes. Most of these events were detected by pharmacists when reviewing electronic prescriptions, which indicates that reviewing physician prescriptions is a routine part of the work of pharmacists. This is consistent with the results of other studies in hospital settings that identified medication-related incidents as the second most important source of safety events [24,25]. An electronic prescription system is used at HMV, and paper prescriptions are no longer accepted, which is not always the case in other hospitals [26,27]. Medication management has important consequences for patient outcomes [28]. Measures such as daily prescription review by pharmacists, including communication with physicians for clarification, have been described in the literature as an important step in promoting patient safety [29].

At HMV, near-miss incidents can be reported by any hospital worker, regardless of occupation. The sole purpose of analyzing these safety incidents is to plan and implement improvements. Reports, such as never event cases, are discussed in monthly management committee meetings by hospital leadership to define priorities or in weekly risk management meetings with inpatient ward managers. Incidents are not necessarily discussed on the same day they occur. In inpatient wards, teams are directly involved in proposing interventions, implementing safety actions, and developing educational activities for the staff, including guidance for physicians about prescription problems. These teams also define mandatory changes in electronic prescription software when necessary.

Analyses of near-miss incidents in each sector revealed some significant associations. For example, incidents related to venous/vascular access, as well as to sterile material, were significantly more frequent in the surgical center and post-anesthesia care unit, whereas fluid balance-related incidents were significantly associated with ICUs and the dialysis unit. Therefore, the reported incident types reflected the procedures performed in each sector. This suggests that critical analysis of near-miss incidents may be useful for developing customized strategies for specific hospital sectors. It should also be pointed out that the majority of near-miss incidents are job-specific, i.e., to nurses, pharmacists or physicians. This could explain the association we found between ICUs and reports of fluid balance incidents, while other analyses showed that near-miss incidents identified by anesthesia providers in ICUs were more likely to be associated with airway management [30].

As described in other Brazilian studies, the highest prevalence of reports was observed in inpatient wards, in the ICU, PICU and NICU, and in surgical center/post-anesthesia care units [25–29]. This could be explained by the higher number of procedures and patients admitted to these units vs. other sectors, as well as to the large number of prescriptions made on a daily basis in these areas. It should be noted analyzing near-miss incidents in these sectors is very important for establishing prevention strategies, since the occurrence of preventable serious adverse events is still common [29–33].

We observed that most near-miss incidents were reported during the day shift. Reporting more than doubled during the four-year study period, and the proportion of medication-related incidents decreased >60%. This reflects aspects such as pharmacist review of prescriptions during the day shift and the fact that incident report training was first implemented in the pharmacy sector. Moreover, night shift workers have less interaction with patients and, thus, fewer opportunities for near-miss incidents. In addition, the electronic prescription system was adjusted to decrease medical errors and prescription phase near-miss incidents, such as duplicate prescriptions for the same patient.

The low adherence of night shift workers to the reporting system could be related to a lack of training programs for them. Thus, we argue that specific strategies are needed to improve night shift worker awareness of the need to report near-miss incidents. In general, night shift workers have less contact with leadership and do not always engage in continuing education programs [34]. Night shift staff also frequently complain of feeling slighted regarding education: they frequently ask to come in early or stay late to participate in educational programs. However, they would prefer specific programs during their work hours. Thus, commitment to and innovation in learning opportunities for night shift workers are a necessity.

It is also worth pointing out that most of the reports were made by pharmacists, nurses, and nursing technicians. These data agree with a previous study, which reported that physicians are the least engaged staff in error reporting, perhaps for fear of legal disputes or professional embarrassment [23]. A systematic review has shown that, among nurses, the main barriers to reporting are organizational, such as organizational culture and type of reporting system [22]. Personal barriers, such as fear of being held responsible still exist. To overcome these obstacles, it is important to implement anonymous, easy-to-use reporting systems that are effective and efficient, as well as to promote a positive attitude in managers and leaders, who should support workers and provide continuing education and feedback. Additionally, near-miss incident reports can be measured quantitatively and provide qualitative data about less evident processes and rationalizations across a range of procedures and settings. These insights provide opportunities to learn about the cause of incidents and support decision-making to prevent their recurrence.

A final strategy for improving practice is to establish risk management processes and initiatives of adequate quality. Every facility should promote a culture of safety that encourages discussing errors and near-miss incidents in a nonpunitive manner. In doing so, effective solutions for specific systems can be identified and implemented.

As a final thought, we argue that near-miss incidents are difficult to research because classification can be subjective. Perceptions about patient danger may change over time and with repeated exposure to hazardous circumstances [35]. In other words, recognition of and experience with near-miss incidents involves a normalization process. Human judgement and hesitation may also play a role in individual decision-making about what is considered a near miss and about the need to report it.

Classifying some near-miss incidents into a general category (“other institutional protocols”) is a limitation, since there was no in-depth analysis of these items. However, we believe the present results were not affected by this limitation due to the large number of events involved, which provided a good overall picture of the phenomenon. It should also be pointed out that the study was performed in an institution with specific characteristics, e.g. being one of only five hospitals in Brazil classified as “excellent” by the Ministry of Health. Thus, the present findings cannot be generalized to all national contexts. Additional research should be conducted in various hospital settings to facilitate strategies to prevent patient harm.

6. Conclusions

We analyzed 12,939 near-miss incidents reported in a general hospital from 1 January 2013 to 24 August 2017. We observed a linear increase in the number of notifications during the study period. The highest prevalence of reports was observed in inpatient wards, in the ICU, the PICU and the NICU, and in surgical center/post-anesthesia care unit. Pharmacists and nursing personnel made most of the reports during the day shift.

The frequency of reported near-miss incidents was highest for medication processes, followed by “other institutional processes” (i.e., unspecified the International Classification for Patient Safety framework), followed by information control in patient charts/fluid balance, followed by venous/vascular puncture.

The high number of near-miss incident reports reflects good staff adherence to the reporting system. We argue that improving safety culture is not necessarily an antecedent to or a consequence of incident reporting. Rather, there is a dynamic relationship that contributes to the establishment of a safety culture with emphasis on organizational learning. In addition, the safety culture (or more specifically, the safety climate) was not evaluated in this study and could be considered in further research. The present findings also suggest the current existence of an environment in which professionals feel comfortable discussing safety incidents, and where they are engaged in designing and implementing strategies to improve safety based on reports of near-miss incidents.