Near-miss analysis in a large hospital in southern Brazil: A 5-year retrospective study

Abstract

BACKGROUND: Near-miss analysis is an effective method for preventing serious adverse events, including never events such as wrong-site surgery. OBJECTIVE: To analyze all near-miss incidents reported in a large general hospital in southern Brazil between January 2013 and August 2017. METHOD: We performed a descriptive retrospective study of near-miss incidents recorded in the hospital’s electronic reporting system in a large non-profit hospital (497 beds). The results are expressed as absolute (n) and relative frequencies (%). Pearson’s chi-square test, Fisher’s exact test (Monte Carlo simulation) and linear regression were used. RESULTS: A total of 12,939 near-miss incidents were recorded during the study period, with linear growth in the number of reports. Near-miss incidents were most frequent for medication, followed by processes unspecified in the International Classification for Patient Safety framework, followed by information control (patient chart and fluid balance data), followed by venous/vascular puncture. The highest prevalence of reports was observed in inpatient wards, in adult, pediatric, and neonatal intensive care units, and in the surgical center/post-anesthesia care unit. Pharmacists and nursing personnel recorded most of the reports during the day shift. CONCLUSION: The most frequent categories of near-miss incidents were medication processes, other institutional protocols, information control issues, and venous/vascular puncture. The significant number of reported near-miss incidents reflects good adherence to the reporting system.