Presentation
Near Miss Identification and Reporting in Perioperative Anesthesia Care
SessionPoster Session 2
DescriptionBackground
In the health care environment, incidents are approximately 3300 times as likely to occur as accidents and adverse events [1]. Root-cause analysis of adverse events is well-documented through morbidity and mortality reports and medical malpractice lawsuits. The 2023 Candello (by CRICO) Benchmarking Report cites a variety of factors that contribute to the adverse events reported in medical malpractice cases, including issues relating to patient assessment (43%), management of therapy (30%), provider communication (18%), and insufficient documentation (16%) [2]. Contrastingly, near misses are typically held to a less-rigorous documentation standard, as these events do not cause immediate patient harm and may even go unnoticed when occurring.
Reporting of these near miss incidents provides knowledge for quality improvement goals and an opportunity to conduct root-cause analysis and strengthen system-level safety [3]. However, compliance of reporting such events is variable across health care systems and is influenced by psychosocial factors, including fear of repercussions, variation in interpretation of events, and lack of knowledge around addressing near-misses [4]. Additionally, difficulty distinguishing between near misses, in which a harmful event is prevented before any action occurs, and no-harm events, in which an action is taken but does not result in harm, may contribute to underreporting.
The potential for near miss events is compounded during high-risk aspects of perioperative care. When near misses go undocumented, these unresolved incidents accumulate and create a dangerous chain of vulnerabilities, increasing the likelihood that a catastrophic event will occur when weaknesses align [5]. This work seeks to understand the gap in near miss reporting and identify the barriers that prevent individuals from documenting these occurrences. Ultimately, identifying the perceptions of near miss events provides the foundation for interventions to improve the amount of near miss reporting, resulting in learning opportunities and improving the departmental culture of safety.
Methods
This study was conducted within the department of anesthesia at a single-center hospital, and anesthesia attending physicians, fellows, residents, nurse anesthetists (CRNAs) and anesthesia technicians were invited to participate via email. A comprehensive survey was conducted to gather perceptions and understanding of near miss events and reporting. The survey requested respondents define events that constitute a near miss, rate the importance of reporting and any barriers to reporting near misses, and identify any recent near miss events that they witnessed. The survey also included two questions that requested respondents identify the near miss event(s) from a list of possible scenarios that could occur under anesthesia care. Data was collected using RedCAP, and responses were tabulated and analyzed using MATLAB. Free response questions were thematically assessed to identify trends among the responses.
Results
The survey was completed by 50 individuals out of 289 recipients of the email communication, resulting in a 17.3% response rate. In response to the question: “Have you ever witnessed a near miss event?” 98% of participants responded “Yes” and 2% responded “Don’t Know.” Contrastingly, the following question, asking if the near miss event was documented, resulted in 44.9% answering “Yes,” while 28.6% reported that the event was not documented and 26.5% reported that they did not know. On a scale of 1 to 100, the median response to the importance of reporting near miss events was 84, while the median response for the likeliness that the participant would report a near miss event was 69.5. Regarding the barriers to reporting near misses, “cumbersome reporting process” was the most frequently selected response (27), followed by “not sure how to report a near miss” (21) and “not sure if it’s a near miss” (19).
Conclusions
These results highlight a notable gap between the recognition of near misses and the frequency with which they are reported. While participants assigned high importance to the reporting of near misses, their reported likelihood of submitting such reports was comparatively lower, suggesting that perceived barriers may deter reporting. The most frequently identified barriers, including the complexity of the reporting procedures, lack of knowledge about the reporting process, and uncertainty about what constitutes a near miss, point to structural and educational challenges that may inhibit consistent reporting practices. These findings suggest that targeted interventions aimed at simplifying reporting mechanisms, clarifying reporting criteria, and improving awareness of reporting procedures may strengthen near miss reporting and, in turn, contribute to broader patient safety initiatives.
References
[1] Webster, C S, Mahajan, R, & Weller, J M. Anaesthesia and patient safety in the socio-technical operating theatre: a narrative review spanning a century. British Journal of Anaesthesia, 2023.
[2] Candello 2023 Benchmarking Report: An Analysis of Advanced Practice Provider and Physician Malpractice Risk. Candello Solutions by CRICO, 2023.
[3] Lipshutz, A.K., Caldwell, J.E., Robinowitz, D.L. et al. An analysis of near misses identified by anesthesia providers in the intensive care unit. BMC Anesthesiol, 2015.
[4] Woodier N, Burnett C, Sampson P, Moppett I. Patient safety near misses – Still missing opportunities to learn. Journal of Patient Safety and Risk Management, 2024.
[5] Wiegmann, D. A., Wood, L. J., Cohen, T. N., Shappell, S. Understanding the “Swiss Cheese Model” and Its Application to Patient Safety. Journal of Patient Safety, 2022.
In the health care environment, incidents are approximately 3300 times as likely to occur as accidents and adverse events [1]. Root-cause analysis of adverse events is well-documented through morbidity and mortality reports and medical malpractice lawsuits. The 2023 Candello (by CRICO) Benchmarking Report cites a variety of factors that contribute to the adverse events reported in medical malpractice cases, including issues relating to patient assessment (43%), management of therapy (30%), provider communication (18%), and insufficient documentation (16%) [2]. Contrastingly, near misses are typically held to a less-rigorous documentation standard, as these events do not cause immediate patient harm and may even go unnoticed when occurring.
Reporting of these near miss incidents provides knowledge for quality improvement goals and an opportunity to conduct root-cause analysis and strengthen system-level safety [3]. However, compliance of reporting such events is variable across health care systems and is influenced by psychosocial factors, including fear of repercussions, variation in interpretation of events, and lack of knowledge around addressing near-misses [4]. Additionally, difficulty distinguishing between near misses, in which a harmful event is prevented before any action occurs, and no-harm events, in which an action is taken but does not result in harm, may contribute to underreporting.
The potential for near miss events is compounded during high-risk aspects of perioperative care. When near misses go undocumented, these unresolved incidents accumulate and create a dangerous chain of vulnerabilities, increasing the likelihood that a catastrophic event will occur when weaknesses align [5]. This work seeks to understand the gap in near miss reporting and identify the barriers that prevent individuals from documenting these occurrences. Ultimately, identifying the perceptions of near miss events provides the foundation for interventions to improve the amount of near miss reporting, resulting in learning opportunities and improving the departmental culture of safety.
Methods
This study was conducted within the department of anesthesia at a single-center hospital, and anesthesia attending physicians, fellows, residents, nurse anesthetists (CRNAs) and anesthesia technicians were invited to participate via email. A comprehensive survey was conducted to gather perceptions and understanding of near miss events and reporting. The survey requested respondents define events that constitute a near miss, rate the importance of reporting and any barriers to reporting near misses, and identify any recent near miss events that they witnessed. The survey also included two questions that requested respondents identify the near miss event(s) from a list of possible scenarios that could occur under anesthesia care. Data was collected using RedCAP, and responses were tabulated and analyzed using MATLAB. Free response questions were thematically assessed to identify trends among the responses.
Results
The survey was completed by 50 individuals out of 289 recipients of the email communication, resulting in a 17.3% response rate. In response to the question: “Have you ever witnessed a near miss event?” 98% of participants responded “Yes” and 2% responded “Don’t Know.” Contrastingly, the following question, asking if the near miss event was documented, resulted in 44.9% answering “Yes,” while 28.6% reported that the event was not documented and 26.5% reported that they did not know. On a scale of 1 to 100, the median response to the importance of reporting near miss events was 84, while the median response for the likeliness that the participant would report a near miss event was 69.5. Regarding the barriers to reporting near misses, “cumbersome reporting process” was the most frequently selected response (27), followed by “not sure how to report a near miss” (21) and “not sure if it’s a near miss” (19).
Conclusions
These results highlight a notable gap between the recognition of near misses and the frequency with which they are reported. While participants assigned high importance to the reporting of near misses, their reported likelihood of submitting such reports was comparatively lower, suggesting that perceived barriers may deter reporting. The most frequently identified barriers, including the complexity of the reporting procedures, lack of knowledge about the reporting process, and uncertainty about what constitutes a near miss, point to structural and educational challenges that may inhibit consistent reporting practices. These findings suggest that targeted interventions aimed at simplifying reporting mechanisms, clarifying reporting criteria, and improving awareness of reporting procedures may strengthen near miss reporting and, in turn, contribute to broader patient safety initiatives.
References
[1] Webster, C S, Mahajan, R, & Weller, J M. Anaesthesia and patient safety in the socio-technical operating theatre: a narrative review spanning a century. British Journal of Anaesthesia, 2023.
[2] Candello 2023 Benchmarking Report: An Analysis of Advanced Practice Provider and Physician Malpractice Risk. Candello Solutions by CRICO, 2023.
[3] Lipshutz, A.K., Caldwell, J.E., Robinowitz, D.L. et al. An analysis of near misses identified by anesthesia providers in the intensive care unit. BMC Anesthesiol, 2015.
[4] Woodier N, Burnett C, Sampson P, Moppett I. Patient safety near misses – Still missing opportunities to learn. Journal of Patient Safety and Risk Management, 2024.
[5] Wiegmann, D. A., Wood, L. J., Cohen, T. N., Shappell, S. Understanding the “Swiss Cheese Model” and Its Application to Patient Safety. Journal of Patient Safety, 2022.
Event Type
Poster Presentation
TimeTuesday, March 244:45pm - 6:15pm EDT
LocationRhinelander Gallery
Hospital Environments