[A near-miss event. A new approach in the study of adverse events].
A near-miss event is defined as an event that could have resulted in an injury, fatality, or property damage if it had not been prevented. Analysis of near-miss events could be an efficient method in the study of adverse events. Reporting of near-misses has many benefits in the study of adverse events since near-misses occur more frequently than adverse events. In addition, as they have no consequences, fear that the professionals involved would have to report them is less. However, up to now, this method has been slow to develop. We present two clinical cases that help to understand the usefulness of the near-miss reporting system.
Gutiérrez Cía
I
I
Servicio de Medicina Intensiva, Hospital Clínico Universitario, Zaragoza, España. igutierrcia@hotmail.com
Obón Azuara
B
B
Aibar Remón
C
C
D000284:Administration, Oral; D000700:Analgesics / Q000008:administration & dosage*; D002406:Catheterization, Peripheral / Q000009:adverse effects*; D003422:Critical Care; D006801:Humans; D007902:Length of Stay; D008297:Male; D008508:Medication Errors / Q000517:prevention & control; D008875:Middle Aged
D000700:Analgesics