What causes near-misses and how are they mitigated?
Nursing
; 43(4): 19-24, 2013 Apr.
Article
em En
| MEDLINE
| ID: mdl-23507944
ABSTRACT
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 near-misses, 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 patient-safety programs. Education about mitigating techniques for near-misses is imperative for RNs.
Texto completo:
1
Coleções:
01-internacional
Base de dados:
MEDLINE
Assunto principal:
Atitude do Pessoal de Saúde
/
Erros Médicos
/
Recursos Humanos de Enfermagem Hospitalar
Tipo de estudo:
Etiology_studies
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Observational_studies
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Prognostic_studies
/
Qualitative_research
/
Risk_factors_studies
Limite:
Humans
Idioma:
En
Revista:
Nursing
Ano de publicação:
2013
Tipo de documento:
Article
País de afiliação:
Estados Unidos