title: A "near-miss" model for describing the nurse's role in the recovery of medical errors.
abstract: Approximately 44,000 patients die each year as a result of medical errors. Nurses play an important role in ensuring patient safety and preventing adverse outcomes. As frontline providers of care, nurses are in key positions to intercept a medical error before it affects a patient. The Eindhoven model for investigating a "near-miss" situation has been used successfully in the chemical industry to elucidate the concept of human recovery, that is, the ability of operators to detect, localize, and correct system faults. In this article, we propose applying the Eindhoven model to the clinical setting, in which nurses play the role of operators by identifying, interrupting, and correcting medical errors. After describing the model, we present clinical scenarios to illustrate how it can be applied. More research is needed to explicate the nurse's role in managing medical errors. Interventions to decrease medical errors require insight into strategies that frontline clinicians can use to identify and mitigate potentially harmful incidents. The Eindhoven model can help researchers, administrators, and clinicians to conceptualize the role for nurses in developing such interventions.
authors.affiliation: School of Nursing, University of Massachusetts, Amherst, MA, USA. bethann953@aol.com
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Henneman
authors.forename: Anna
authors.initials: A
authors.lastname: Gawlinski
mesh_terms: D004342:Drug Hypersensitivity / Q000517:prevention & control; D006801:Humans; D008297:Male; D019300:Medical Errors / Q000517:prevention & control*; D008875:Middle Aged; D017146:Models, Organizational; D009203:Myocardial Infarction / Q000188:drug therapy / Q000451:nursing; D024802:Nurse's Role; D009741:Nursing Staff, Hospital / Q000458:organization & administration*; D012308:Risk Management / Q000458:organization & administration*