A “near miss” (good catch/close call) is an unplanned occurrence that could have caused harm but is prevented from reaching the patient, either through timely intervention – by staff, families or patients – or by chance.
For several years, quality and safety experts have suggested that near miss reporting is valuable for healthcare organizations to foster a rich safety culture. Lessons learned from near miss events can be applied directly to potentially harmful situations, preventing the possibility of patient harm in the future.
Dr. Adele Harrison, Medical Director at Island Health, sees tremendous value in near miss reporting, and is encouraging staff to report these events in PSLS. She says near miss data is vital for Island Health to strengthen its safety culture – something the organization’s leaders are focused on in 2015 – and that staff should be recognized for reporting events that could have caused patient harm.
“Through my experience as a clinician in the Neonatal Intensive Care Unit (NICU), I know near miss events are normally dealt with in the moment,” says Adele. “I think that’s great because we’re preventing harm from happening, but we’re not capturing that information in PSLS as much as I’d like. So we’re asking staff to report about near miss events that happened during their work day, so we can collect this information and proactively address issues that keep coming up.”
Adele says Island Health is committed to promoting a culture of learning and improvement, and near miss reporting is an important part of the organization’s focus on cultural change.
“That’s why we’re also asking managers to review near miss events in PSLS and discuss their findings with their teams. That way we can identify areas for improvement together, and target specific strategies across all areas of patient care at Island Health.”
To encourage near miss reporting by staff across Island Health, a competition was held in October 2014 that culminated with Canadian Patient Safety Week. More than 300 events from across program areas were submitted, making it an exciting first step to bringing Island Health together around near miss reporting. Participation extended beyond those who submitted events during Patient Safety Week. Island Health staff members visited an e-learning hub to vote for one of the four short-listed reports to select the coveted “Catch of the Week.”
“I think the ‘Catch of the Day’ competition motivated staff because it built a positive space to speak about the impacts of near-miss reporting – plus we offered a great prize (tickets to the 2015 Quality Forum),” says Jennie Aitken, BC PSLS Coordinator. “I believe the real benefit is that we’re now seeing proactive conversations about safety on a regular basis, a greater sense of accountability among staff, and that’s what we were really hoping for.”
Nancy Kroes, Coordinator, Integrated Services at Oceanside Health Centre, believes it’s important for staff to feel comfortable reporting events that could have happened, and says she’s encouraged her staff to report near misses in PSLS since the centre opened in 2013. For Nancy and her team, winning the Catch of the Day contest by popular vote was an unexpected but welcome surprise!
“At the Oceanside Health Centre, we provide in home care, ambulatory care (urgent care and support clinic) and primary care services to the clients living in Parksille, Qualicum and the surrounding areas,” says Nancy. “Many of our patients are elderly with multiple health concerns, so our team works closely to ensure the level of care we provide is focused around the unique needs of each client.”
It was during a routine assessment of a client with severe dementia that Lenore Bailey, Case Manager, Integrated Community Care Team, discovered several undocumented medication allergies that put the client at risk for serious health complications.
“I interviewed this client in her home,” says Lenore. “If her daughter hadn’t been there I wouldn’t have known about her mother’s medication allergies because the client’s electronic record indicated No Known Allergies.”
Nancy says if this client had a fall in the middle of the night and ended up in hospital, she wouldn’t have had the cognitive ability to inform staff about her allergies. “This kind of situation can be very dangerous, perhaps even fatal.”
She says that’s why it’s important to have someone present during assessments of clients with dementia or to review the reported allergies with a caregiver who can confirm the information. In addition, this case led to updates to the “medication allergies” process so serious allergies are unlikely to be missed in the future. “All in all, this has been a really interesting learning experience and there have been several positive changes that will benefit all clients.”
Adele says Oceanside’s experience is a great example of why near miss reporting is so important and why Island Health leaders want to see more of these events captured in PSLS.
“Our aim is to prevent harm from happening, but we also want to promote a culture where patient safety is at the core of everything we do at Island Health. I truly believe everyone working here has the power to influence positive change. If we continue to increase near miss reporting as we have been these past few months, I feel very optimistic about where we’re headed as an organization.”
Congratulations to all Island Health staff!
BC PSLS Central Office would like to thank Adele Harrison, Jennie Aitken, Nancy Kroes, and Lenore Bailey for sharing their story with us!
The following websites provide more information about near misses and safety culture: