Patient safety near misses – Still missing opportunities to learn

Abstract

Objectives A patient safety near miss is a safety event that had the potential to cause harm, but did not reach the patient. For over 20 years healthcare has been exhorted to learn from patient safety near misses to support improvements in patient safety. The belief is that, by addressing the factors that contribute to patient safety near misses, harmful incidents will be avoided. However, there seems to have been little progress made to learn from patient safety near misses. This study aimed to explore why there has been limited progress, and how best patient safety near misses may be learned from. Methods A qualitative case study was undertaken to explore the learning from patient safety near misses in different National Health Service contexts. Semi-structured interviews were conducted with patient safety leads in secondary care, primary care, and regional/national bodies. Interviews were recorded, transcribed, and thematically analysed. Results Seventeen interviews were undertaken across the National Health Service, with further data collected from policy, guidance, field notes, and research memos. Thematic analysis identified the following: variations in safety event schema; limited processes for patient safety near misses; unsupportive reporting contexts; and assumed, but non-evidenced improvements in patient safety. Participants also shared their thoughts on how learning from patient safety near misses could be improved. Conclusion A lack of progress has been made to learn from patient safety near misses in the National Health Service. This is contributed to by a lack of agreement about what is and how best to learn from a patient safety near miss. The learning value of patient safety near misses lies in the focus they place on controls to hazards, but they should not be learned from in isolation.