title: What causes near-misses and how are they mitigated?
abstract: OBJECTIVE
  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.
authors.affiliation: At Inova Fair Oaks Hospital in Fairfax, Va., Karen Gabel Speroni is a nursing research scientist, Judith Fisher is the former director of clinical operations, Marie Dennis is the former chief nursing of&filig;cer, and Marlon Daniel is a biostatistician.
authors.forename: Karen Gabel
authors.initials: KG
authors.lastname: Speroni
authors.forename: Judith
authors.initials: J
authors.lastname: Fisher
authors.forename: Marie
authors.initials: M
authors.lastname: Dennis
authors.forename: Marlon
authors.initials: M
authors.lastname: Daniel
mesh_terms: D006801:Humans; D000067491:Near Miss, Healthcare; D012308:Risk Management / Q000379:methods*; D011795:Surveys and Questionnaires